Healthcare Provider Details

I. General information

NPI: 1649026022
Provider Name (Legal Business Name): 30TH & O
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2024
Last Update Date: 05/01/2024
Certification Date: 05/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 PARK EAST DR APT 539
BEACHWOOD OH
44122-4358
US

IV. Provider business mailing address

3600 PARK EAST DR APT 539
BEACHWOOD OH
44122-4358
US

V. Phone/Fax

Practice location:
  • Phone: 440-213-9459
  • Fax:
Mailing address:
  • Phone: 440-213-9459
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JACLYN TOMSIC
Title or Position: PRESIDENT
Credential: MD
Phone: 440-213-9459