Healthcare Provider Details

I. General information

NPI: 1841372935
Provider Name (Legal Business Name): CRANIOFACIAL IMAGING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10900 EUCLID AVE CASE SCHOOL OF DENTAL MEDICINE - 3RD FLOOR
CLEVELAND OH
44106-1712
US

IV. Provider business mailing address

10900 EUCLID AVE CASE SCHOOL OF DENTAL MEDICINE - 3RD FLOOR
CLEVELAND OH
44106-1712
US

V. Phone/Fax

Practice location:
  • Phone: 216-368-2674
  • Fax: 216-368-3204
Mailing address:
  • Phone: 216-368-2674
  • Fax: 216-368-3204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number16067
License Number StateOH

VIII. Authorized Official

Name: DR. MARK G HANS
Title or Position: CHAIRMAN
Credential: DDS, MSD
Phone: 216-368-4649