Healthcare Provider Details

I. General information

NPI: 1871794131
Provider Name (Legal Business Name): RIVERSIDE FAMILY DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

547 SPINNING RD
DAYTON OH
45431-2157
US

IV. Provider business mailing address

547 SPINNING RD
DAYTON OH
45431-2157
US

V. Phone/Fax

Practice location:
  • Phone: 937-252-1463
  • Fax:
Mailing address:
  • Phone: 937-252-1463
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number18186
License Number StateOH

VIII. Authorized Official

Name: JONELL L. VOSKUHL
Title or Position: ADMINISTRATOR
Credential:
Phone: 937-376-9975