MEDICARE: CENTERVILLE DENTAL CENTER OHIO LLC

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

General Provider Information

NPI Number	:	1427515667
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTERVILLE DENTAL CENTER OHIO LLC

Provider Business Mailing Address
First Line	:	9346 DAYTON LEBANON PIKE
Second Line	:
City	:	CENTERVILLE
State	:	OH
Zip	:	45458-3839
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9346 DAYTON LEBANON PIKE
Second Line	:
City	:	CENTERVILLE
State	:	OH
Zip	:	45458-3839
Country	:	US
Telephone Number	:	937-435-4150
Fax Number	:

Authorized Official
Title or Position	:	COO
Name	:	OPAL ANDERSON
Credential	:
Telephone Number	:	937-435-4150

Provider Enumeration Date	:	02/25/2019
Last Update Date	:	07/20/2022

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