1659471605 NPI number — GENERAL RECONSTRUCTIVE & COSMETIC DENTISTRY INC

Table of content: CHYANNE LORETTA MENNELL LCSW (NPI 1760346076)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659471605 NPI number — GENERAL RECONSTRUCTIVE & COSMETIC DENTISTRY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GENERAL RECONSTRUCTIVE & COSMETIC DENTISTRY 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:
1659471605
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3349 EXECUTIVE PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOLEDO
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43606
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-578-2380
Provider Business Mailing Address Fax Number:
419-578-2381

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3349 EXECUTIVE PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TOLEDO
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43606
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-578-2380
Provider Business Practice Location Address Fax Number:
419-578-2381
Provider Enumeration Date:
09/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KOZY
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
S
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
419-578-2380

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  15171 , 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)





Copyright © 2007-2025 www.npivalidator.com