Healthcare Provider Details

I. General information

NPI: 1881867778
Provider Name (Legal Business Name): CHILDREN'S SMILES DENTAL CARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2008
Last Update Date: 04/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2969 BLUE JACKET CT.
LIMA OH
45806-1464
US

IV. Provider business mailing address

2969 BLUE JACKET CT
LIMA OH
45806-1464
US

V. Phone/Fax

Practice location:
  • Phone: 419-229-3007
  • Fax:
Mailing address:
  • Phone: 419-229-3007
  • Fax: 419-229-0214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number30020325
License Number StateOH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2354429
Identifier TypeMEDICAID
Identifier StateOH
Identifier Issuer

VIII. Authorized Official

Name: DR. TYRA L MEYER
Title or Position: PEDIATRIC DENTIST
Credential: DDSMS
Phone: 419-229-3007