1477851251 NPI number — HUDEC DENTAL CENTER OF MENTOR, INC.

Table of content: (NPI 1477851251)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477851251 NPI number — HUDEC DENTAL CENTER OF MENTOR, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HUDEC DENTAL CENTER OF MENTOR, INC.
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:
1477851251
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/21/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3327 BROADVIEW RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEVELAND
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44109-3360
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
216-485-5788
Provider Business Mailing Address Fax Number:
216-485-1257

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7697 MENTOR AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MENTOR
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44060-5540
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-530-3500
Provider Business Practice Location Address Fax Number:
440-530-3429
Provider Enumeration Date:
03/03/2011

Additional Information

Authorized Official

Authorized Official Last Name:
HUDEC
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
216-485-5788

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  30-015265 , 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)

  • Identifier: 3126003 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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