MEDICARE: COLUMBUS ADVANCED FAMILY DENTISTRY

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	1223D0001X	Public Health Dentistry	13003577A	IN

General Provider Information

NPI Number	:	1891137865
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLUMBUS ADVANCED FAMILY DENTISTRY

Provider Business Mailing Address
First Line	:	3158 N NATIONAL RD
Second Line	:
City	:	COLUMBUS
State	:	IN
Zip	:	47201-3170
Country	:	US
Telephone Number	:	812-603-3996
Fax Number	:	812-376-0459

Provider Business Practice Location Address
First Line	:	3158 N NATIONAL RD
Second Line	:
City	:	COLUMBUS
State	:	IN
Zip	:	47201-3170
Country	:	US
Telephone Number	:	812-603-3996
Fax Number	:	812-376-0459

Authorized Official
Title or Position	:	CEO
Name	:	PROF. MARVIN PAVLOV
Credential	:	J.D., M.S., M.B.A
Telephone Number	:	812-603-3996

Provider Enumeration Date	:	07/19/2013
Last Update Date	:	07/19/2013

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