Basic Information
Provider Information | |||||||||
NPI: | 1699301721 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GERAMITA | ||||||||
FirstName: | JANET | ||||||||
MiddleName: | LYNN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DENTAL HYGIENIST | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | AMODIE | ||||||||
OtherFirstName: | JANET | ||||||||
OtherMiddleName: | LYNN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1070 OLD NATIONAL PIKE | ||||||||
Address2: |   | ||||||||
City: | FREDERICKTOWN | ||||||||
State: | PA | ||||||||
PostalCode: | 153332114 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7246326801 | ||||||||
FaxNumber: | 7246326312 | ||||||||
Practice Location | |||||||||
Address1: | 1070 OLD NATIONAL PIKE | ||||||||
Address2: |   | ||||||||
City: | FREDERICKTOWN | ||||||||
State: | PA | ||||||||
PostalCode: | 153332114 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7246326801 | ||||||||
FaxNumber: | 7246326312 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/20/2020 | ||||||||
LastUpdateDate: | 03/20/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/20/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | DH069433 | PA | Y |   | Dental Providers | Dental Hygienist |   |
ID Information
ID | Type | State | Issuer | Description | 1007288440027 | 05 | PA |   | MEDICAID |