1093345290 NPI number — GRUELLE ISON ORTHODONTICS LLC

Table of content: (NPI 1093345290)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093345290 NPI number — GRUELLE ISON ORTHODONTICS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRUELLE ISON ORTHODONTICS LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093345290
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/06/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4845 RIALTO RD STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST CHESTER
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45069-2910
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-772-6500
Provider Business Mailing Address Fax Number:
513-772-2002

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9825 COLERAIN AVE STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CINCINNATI
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45251-1554
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-772-6500
Provider Business Practice Location Address Fax Number:
513-772-2002
Provider Enumeration Date:
01/16/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ISON
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
513-772-6500

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: NONE . This is a "NONE" identifier . This identifiers is of the category "OTHER".