Healthcare Provider Details

I. General information

NPI: 1316576556
Provider Name (Legal Business Name): PETR ALEXANDER VAUGHAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2020
Last Update Date: 10/01/2024
Certification Date: 10/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6558 GLENWAY AVE
CINCINNATI OH
45211-4410
US

IV. Provider business mailing address

5310 WAKEFIELD PL
NORWOOD OH
45212-1737
US

V. Phone/Fax

Practice location:
  • Phone: 513-613-3232
  • Fax:
Mailing address:
  • Phone: 937-245-0390
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number30026130
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: