1649437336 NPI number — STREETSBORO DENTAL PARTNERS INC

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 1649437336 NPI number — STREETSBORO DENTAL PARTNERS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STREETSBORO DENTAL PARTNERS 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:
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:
1649437336
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/28/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2006
Provider Second Line Business Mailing Address:
1727 STREETSBORO PLAZA
Provider Business Mailing Address City Name:
STREETSBORO
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44241-0006
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-626-3814
Provider Business Mailing Address Fax Number:
330-626-2169

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1727 STREETSBORO PLZ
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STREETSBORO
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44241-5635
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-626-3814
Provider Business Practice Location Address Fax Number:
330-626-2169
Provider Enumeration Date:
05/20/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HARTMAN
Authorized Official First Name:
LYDIA
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING ADMINISTRATOR
Authorized Official Telephone Number:
330-626-3814

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  20624 , 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: 2029361 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".