Healthcare Provider Details

I. General information

NPI: 1982142113
Provider Name (Legal Business Name): RIVERFAMILYDENTALPRESENTEDBYDR.MANALSUNNADDSLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2017
Last Update Date: 02/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4163 PEARL RD 28651 TOUCHSTONE CIR
CLEVELAND OH
44109-3332
US

IV. Provider business mailing address

4163 PEARL RD 28651 TOUCHSTONE CIR
CLEVELAND OH
44109-3332
US

V. Phone/Fax

Practice location:
  • Phone: 440-454-4878
  • Fax: 216-862-3585
Mailing address:
  • Phone: 440-454-4878
  • Fax: 216-862-3585

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: CATHRYN BUCKNER
Title or Position: OFFICE MANAGER
Credential: DENTAL ASSITANT
Phone: 216-268-3060