Healthcare Provider Details

I. General information

NPI: 1912600263
Provider Name (Legal Business Name): JUAN PABLO CASTRO CUELLAR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2023
Last Update Date: 11/24/2025
Certification Date: 11/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 W 12TH AVE
COLUMBUS OH
43210-1267
US

IV. Provider business mailing address

305 W 12TH AVE
COLUMBUS OH
43210-1267
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number71.000297
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code1223X0008X
TaxonomyOral and Maxillofacial Radiology Dentistry
License Number71.000297
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: