Basic Information
| Provider Information | |||||||||
| NPI: | 1679928568 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ASPEN DENTAL OF ERIE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3189 | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132203189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8662738204 | ||||||||
| FaxNumber: | 3154105531 | ||||||||
| Practice Location | |||||||||
| Address1: | 2049 INTERCHANGE RD | ||||||||
| Address2: | |||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165098315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8148641500 | ||||||||
| FaxNumber: | 8148649480 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2016 | ||||||||
| LastUpdateDate: | 04/28/2016 | ||||||||
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| AuthorizedOfficialLastName: | BERTOLLINI | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRS | ||||||||
| AuthorizedOfficialTelephone: | 8662738204 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist |
No ID Information.