Healthcare Provider Details

I. General information

NPI: 1538128970
Provider Name (Legal Business Name): PEDIATRIC DENTISTRY, JOHN A. GENNANTONIO, D.D.S., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7801 BEECHMONT AVE SUITE 5
CINCINNATI OH
45255-4211
US

IV. Provider business mailing address

7801 BEECHMONT AVE SUITE 5
CINCINNATI OH
45255-4211
US

V. Phone/Fax

Practice location:
  • Phone: 513-474-6777
  • Fax: 513-474-2326
Mailing address:
  • Phone: 513-474-6777
  • Fax: 513-474-2326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number30019420
License Number StateOH

VIII. Authorized Official

Name: TRACEY GRAF
Title or Position: OFFICE MANAGER
Credential:
Phone: 513-474-6777