Healthcare Provider Details

I. General information

NPI: 1295567212
Provider Name (Legal Business Name): DR. IVAN GEORGESE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2024
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4359 KEYSTONE DR
MAUMEE OH
43537-8709
US

IV. Provider business mailing address

8640 WAUKEGAN RD UNIT 531
MORTON GROVE IL
60053-2226
US

V. Phone/Fax

Practice location:
  • Phone: 419-893-0221
  • Fax:
Mailing address:
  • Phone: 224-703-7640
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number30.028276
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: