1871608380 NPI number — DENTAL CLINIC COLLEGE OF DENTISTRY

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 1871608380 NPI number — DENTAL CLINIC COLLEGE OF DENTISTRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DENTAL CLINIC COLLEGE OF DENTISTRY
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:
1871608380
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/17/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
305 W 12TH AVE
Provider Second Line Business Mailing Address:
ROOM 1130 POSTLE HALL
Provider Business Mailing Address City Name:
COLUMBUS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43210-1267
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
614-292-6983
Provider Business Mailing Address Fax Number:
614-688-3671

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
305 W 12TH AVE
Provider Second Line Business Practice Location Address:
ROOM 1130 POSTLE HALL
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43210-1267
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
614-292-6983
Provider Business Practice Location Address Fax Number:
614-688-3671
Provider Enumeration Date:
08/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FISCHBACH
Authorized Official First Name:
HENRY
Authorized Official Middle Name:
Authorized Official Title or Position:
ASSISTANT DEAN
Authorized Official Telephone Number:
614-292-0050

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)

  • Identifier: 2412535+0098193 . This is a "BCMH GENERAL COLLEGE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 316025986028 . This is a "CARESOURCE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2414024+0098193 . This is a "BCMH ORTHODONTICS COLLEGE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 88300 . This is a "DELTA DENTAL" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0098193 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 54350690400 . This is a "BUREAU OF WORKMAN'S COMP" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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