Healthcare Provider Details

I. General information

NPI: 1710522958
Provider Name (Legal Business Name): TERA POOLE DDS, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2019
Last Update Date: 08/24/2021
Certification Date: 08/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8050 HOSBROOK RD STE 310
CINCINNATI OH
45236-2907
US

IV. Provider business mailing address

5361 GRAND VISTA CT
CINCINNATI OH
45227-1955
US

V. Phone/Fax

Practice location:
  • Phone: 513-772-6500
  • Fax:
Mailing address:
  • Phone: 513-560-0212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number30.025691
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number104695
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number30.025691
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: