Healthcare Provider Details

I. General information

NPI: 1265642748
Provider Name (Legal Business Name): DAYTON DENTAL CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 01/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 WOODMAN DR
DAYTON OH
45432-1400
US

IV. Provider business mailing address

1010 WOODMAN DR
DAYTON OH
45432-1400
US

V. Phone/Fax

Practice location:
  • Phone: 937-252-2000
  • Fax: 937-252-1224
Mailing address:
  • Phone: 937-252-2000
  • Fax: 937-252-1224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number30016151
License Number StateOH

VIII. Authorized Official

Name: GARIMA GUPTA
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 937-424-2215