Healthcare Provider Details

I. General information

NPI: 1356407258
Provider Name (Legal Business Name): MID OHIO ORAL SURGERY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4488 W BROAD ST
COLUMBUS OH
43228-5610
US

IV. Provider business mailing address

4488 W BROAD ST
COLUMBUS OH
43228-5610
US

V. Phone/Fax

Practice location:
  • Phone: 614-878-7778
  • Fax: 614-878-2725
Mailing address:
  • Phone: 614-878-7778
  • Fax: 614-878-2725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. PHILLIP T LATHAM
Title or Position: PRESIDENT - SURGEON
Credential: D.D.S.
Phone: 61418787778