Healthcare Provider Details

I. General information

NPI: 1831543701
Provider Name (Legal Business Name): EAST COLUMBUS ORAL SURGERY SPECIALISTS INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2016
Last Update Date: 04/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6555 E BROAD ST.
COLUMBUS OH
43213
US

IV. Provider business mailing address

6555 E BROAD ST.
COLUMBUS OH
43213
US

V. Phone/Fax

Practice location:
  • Phone: 614-427-0400
  • Fax: 614-427-0735
Mailing address:
  • Phone: 614-427-0400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number30023253
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number30022741
License Number StateOH

VIII. Authorized Official

Name: DOUGLAS VON KAENEL
Title or Position: OWNER / SURGEON
Credential: D.D.S.
Phone: 614-427-0400