1124491691 NPI number — BEAVERCREEK FAMILY DENTAL GREGORY J AUSTRIA DDS LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124491691 NPI number — BEAVERCREEK FAMILY DENTAL GREGORY J AUSTRIA DDS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BEAVERCREEK FAMILY DENTAL GREGORY J AUSTRIA DDS 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:
6
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:
1124491691
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/05/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1289 N MONROE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
XENIA
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45385-1655
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-376-9975
Provider Business Mailing Address Fax Number:
937-376-8252

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4049 DAYTON XENIA RD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
BEAVERCREEK
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45432-1992
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-429-3880
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/05/2015

Additional Information

Authorized Official

Authorized Official Last Name:
AUSTRIA
Authorized Official First Name:
GREGORY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
937-376-9975

Provider Taxonomy Codes

  • Taxonomy code: 122300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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