# NEPA DENTAL GROUP, INC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** NEPA Dental - West
- **Organization subpart:** No

## Provider details

- **NPI number:** 1669082632
- **Authorized official:** JOHN ALBERT COSTELLO DMD (VICE PRESIDENT)
- **Authorized official phone:** (570) 655-7645

## Contact information

- **Practice address:** 920 WYOMING AVE STE 104, FORTY FORT, PA 18704-3970
- **Practice address phone:** (570) 283-2422
- **Practice address fax:** (570) 283-1492
- **Mailing address:** 457 N MAIN ST STE 100, PITTSTON, PA 18640-2185
- **Mailing address phone:** (570) 655-7645
- **Mailing address fax:** (570) 299-7427

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223G0001X | General Practice Dentistry | — | NULL | Yes |
| 1223G0001X | General Practice Dentistry | — | — | Yes |

## Other

- **Enumeration date:** 08/05/2020
- **Last updated:** 08/05/2020