Provider Demographics
NPI:1447548854
Name:PROGRESSIVE DENTAL OF MONTROSE, LLC
Entity type:Organization
Organization Name:PROGRESSIVE DENTAL OF MONTROSE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:DEAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:607-754-2273
Mailing Address - Street 1:57 PUBLIC AVE
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:PA
Mailing Address - Zip Code:18801-1219
Mailing Address - Country:US
Mailing Address - Phone:570-278-1186
Mailing Address - Fax:570-278-1873
Practice Address - Street 1:57 PUBLIC AVE
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:PA
Practice Address - Zip Code:18801-1219
Practice Address - Country:US
Practice Address - Phone:570-278-1186
Practice Address - Fax:570-278-1873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-19
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty