Healthcare Provider Details

I. General information

NPI: 1164537684
Provider Name (Legal Business Name): OHIO STATE DENTAL FACULTY PRACTICE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 11/09/2021
Certification Date: 11/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 W. 12TH AVENUE 4TH FLOOR POSTLE HALL
COLUMBUS OH
43210-1267
US

IV. Provider business mailing address

305 W 12TH AVE 2301 POSTLE HALL
COLUMBUS OH
43210-1267
US

V. Phone/Fax

Practice location:
  • Phone: 614-292-1472
  • Fax: 614-688-3553
Mailing address:
  • Phone: 614-292-1472
  • Fax: 614-688-3553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: MRS. LINDA MURRAY MYERS
Title or Position: DIRECTOR
Credential: MHHA
Phone: 614-688-4378