Healthcare Provider Details

I. General information

NPI: 1356387542
Provider Name (Legal Business Name): EDWARD DESATNIK D.D.S.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12105 SHERATON LN
CINCINNATI OH
45246-1613
US

IV. Provider business mailing address

12105 SHERATON LN
CINCINNATI OH
45246-1613
US

V. Phone/Fax

Practice location:
  • Phone: 513-671-6722
  • Fax: 513-985-9014
Mailing address:
  • Phone: 513-671-6722
  • Fax: 513-985-9014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number30.010761
License Number StateOH

VIII. Authorized Official

Name: DR. EDWARD DESATNIK
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 513-671-6722