MEDICARE: MARION DENTAL ASSOCIATES SANDU 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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1861991267
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARION DENTAL ASSOCIATES SANDU LLC

Provider Business Mailing Address
First Line	:	1241 E CENTER ST
Second Line	:
City	:	MARION
State	:	OH
Zip	:	43302-4446
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1241 E CENTER ST
Second Line	:
City	:	MARION
State	:	OH
Zip	:	43302-4446
Country	:	US
Telephone Number	:	740-387-4804
Fax Number	:

Authorized Official
Title or Position	:	REGIONAL OPERATIONS MANAGER
Name	:	OPAL F ANDERSON
Credential	:
Telephone Number	:	740-387-4804

Provider Enumeration Date	:	02/12/2018
Last Update Date	:	07/20/2022

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