Healthcare Provider Details

I. General information

NPI: 1780228767
Provider Name (Legal Business Name): DEAK MEDICAL DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2019
Last Update Date: 12/10/2019
Certification Date: 12/10/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 ABBE RD N
ELYRIA OH
44035-1600
US

IV. Provider business mailing address

1212 ABBE RD N
ELYRIA OH
44035-1600
US

V. Phone/Fax

Practice location:
  • Phone: 440-366-3325
  • Fax: 440-366-6611
Mailing address:
  • Phone: 440-366-3325
  • Fax: 440-366-6611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: MICHELE R KIRBY
Title or Position: OFFICE MANAGER
Credential:
Phone: 440-366-3325