Provider Demographics
NPI:1548449176
Name:BEAVER VALLEY DENTAL, LLC
Entity type:Organization
Organization Name:BEAVER VALLEY DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CIARIMBOLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-266-2099
Mailing Address - Street 1:546 MERCHANT ST
Mailing Address - Street 2:
Mailing Address - City:AMBRIDGE
Mailing Address - State:PA
Mailing Address - Zip Code:15003-2463
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:546 MERCHANT ST
Practice Address - Street 2:
Practice Address - City:AMBRIDGE
Practice Address - State:PA
Practice Address - Zip Code:15003-2463
Practice Address - Country:US
Practice Address - Phone:724-266-2099
Practice Address - Fax:724-266-5388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-31
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0364321223G0001X
PADS030094L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1018235160001Medicaid
PA0017686540006Medicaid