Healthcare Provider Details

I. General information

NPI: 1104059658
Provider Name (Legal Business Name): CASE DENTAL MEDICINE SUPPORT SERVICES, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2009
Last Update Date: 06/22/2021
Certification Date: 06/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9601 CHESTER AVE SUITE 154
CLEVELAND OH
44106-1666
US

IV. Provider business mailing address

P.O. BOX 415
CHESTERLAND OH
44026-0415
US

V. Phone/Fax

Practice location:
  • Phone: 216-368-3102
  • Fax: 216-368-4338
Mailing address:
  • Phone: 440-729-3399
  • Fax: 440-729-6001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number StateOH

VIII. Authorized Official

Name: MR. DALE A. BAUR SR.
Title or Position: DEPARTMENT CHAIR
Credential: DDS
Phone: 216-368-3102