Healthcare Provider Details

I. General information

NPI: 1285445288
Provider Name (Legal Business Name): 614 DENTAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2025
Last Update Date: 01/17/2025
Certification Date: 01/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81 S 4TH ST STE 205
COLUMBUS OH
43215-4308
US

IV. Provider business mailing address

2028 FLORAL AVE
COLUMBUS OH
43223-1106
US

V. Phone/Fax

Practice location:
  • Phone: 614-588-8200
  • Fax:
Mailing address:
  • Phone: 614-632-3150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TARA HERMAN
Title or Position: OWNER / OFFICE MANAGER
Credential:
Phone: 614-632-3150