Healthcare Provider Details

I. General information

NPI: 1962730549
Provider Name (Legal Business Name): DENTAL EXPRESS BOARDMAN, TED A SCHUSTER DDS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2009
Last Update Date: 07/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6540 SOUTH AVE
BOARDMAN OH
44512-3651
US

IV. Provider business mailing address

6540 SOUTH AVE
BOARDMAN OH
44512-3651
US

V. Phone/Fax

Practice location:
  • Phone: 330-533-3400
  • Fax:
Mailing address:
  • Phone: 330-533-3400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number30022311
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number30015046
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number30-012873
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number30-01955
License Number StateOH
# 5
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number30-022882
License Number StateOH
# 6
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number30-023087
License Number StateOH
# 7
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number30020654
License Number StateOH

VIII. Authorized Official

Name: AMY R MAUERMAN
Title or Position: ADMINISTRATIVE DIRECTOR
Credential:
Phone: 330-533-3400