1316253149 NPI number — GREAT LAKES DENTALOF WESTLAKE 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 1316253149 NPI number — GREAT LAKES DENTALOF WESTLAKE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREAT LAKES DENTALOF WESTLAKE 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:
1316253149
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/28/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19111 DETROIT RD STE 206
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCKY RIVER
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44116-1740
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-617-9429
Provider Business Mailing Address Fax Number:
440-356-2090

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25101 DETROIT RD
Provider Second Line Business Practice Location Address:
SUITE 445
Provider Business Practice Location Address City Name:
WESTLAKE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44145-2552
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-617-9429
Provider Business Practice Location Address Fax Number:
440-617-9457
Provider Enumeration Date:
08/31/2010

Additional Information

Authorized Official

Authorized Official Last Name:
SANDOVAL
Authorized Official First Name:
STAFANI
Authorized Official Middle Name:
Authorized Official Title or Position:
INSURANCE SPECIALIST
Authorized Official Telephone Number:
440-356-2089

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  022436 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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