Healthcare Provider Details

I. General information

NPI: 1225204126
Provider Name (Legal Business Name): LORAIN COUNTY HEALTH & DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2008
Last Update Date: 02/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3745 GROVE AVE
LORAIN OH
44055-2734
US

IV. Provider business mailing address

1800 LIVINGSTON AVE
LORAIN OH
44052-3781
US

V. Phone/Fax

Practice location:
  • Phone: 440-240-1655
  • Fax: 440-245-1218
Mailing address:
  • Phone: 440-240-1655
  • Fax: 440-245-1218

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: STEPHANIE WIERSMA
Title or Position: PRESIDENT & CEO
Credential:
Phone: 440-233-1059