MEDICARE: AFFORDABLE DENTURES - BROOK PARK, BRIANW. REDDITT, DMD, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	30.023701	OH

General Provider Information

NPI Number	:	1063813228
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AFFORDABLE DENTURES - BROOK PARK, BRIANW. REDDITT, DMD, INC.

Provider Business Mailing Address
First Line	:	5859 SMITH RD
Second Line	:
City	:	BROOKPARK
State	:	OH
Zip	:	44142-2005
Country	:	US
Telephone Number	:	216-898-5812
Fax Number	:	216-898-5815

Provider Business Practice Location Address
First Line	:	5859 SMITH RD
Second Line	:
City	:	BROOKPARK
State	:	OH
Zip	:	44142-2005
Country	:	US
Telephone Number	:	216-898-5812
Fax Number	:	216-898-5815

Authorized Official
Title or Position	:	OWNER
Name	:	BRAIN W REDDITT
Credential	:
Telephone Number	:	216-898-5812

Provider Enumeration Date	:	09/08/2014
Last Update Date	:	09/08/2014

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