Healthcare Provider Details

I. General information

NPI: 1588873285
Provider Name (Legal Business Name): CHILDREN'S DENTAL SPECIALISTS OF LAKE COUNTY, DRS. RICHARDS AND MILLER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 03/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8484 MARKET ST
MENTOR OH
44060-4169
US

IV. Provider business mailing address

8484 MARKET ST
MENTOR OH
44060-4169
US

V. Phone/Fax

Practice location:
  • Phone: 440-266-1740
  • Fax: 440-266-1746
Mailing address:
  • Phone: 440-266-1740
  • Fax: 440-951-1246

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number18409
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number18715
License Number StateOH

VIII. Authorized Official

Name: DR. LISA ANNE RICHARDS
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 440-266-1740