Healthcare Provider Details

I. General information

NPI: 1073528733
Provider Name (Legal Business Name): ADVANCED DERMATOLOGY OF NORTH CENTRAL OHIO INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

770 BALGREEN DR STE 201
MANSFIELD OH
44906-4106
US

IV. Provider business mailing address

PO BOX 735056
DALLAS TX
75373-5056
US

V. Phone/Fax

Practice location:
  • Phone: 419-756-1600
  • Fax: 419-775-1196
Mailing address:
  • Phone: 419-756-1600
  • Fax: 419-775-1196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number35063717T
License Number StateOH

VIII. Authorized Official

Name: DR. CHRIST JOHN TICORAS
Title or Position: OWNER/PRESIDENT
Credential: M.D.
Phone: 419-756-1600