Healthcare Provider Details

I. General information

NPI: 1023532421
Provider Name (Legal Business Name): DDC ENDODONTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2017
Last Update Date: 05/26/2021
Certification Date: 05/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7081 PEARL ROAD
MIDDLEBURG HEIGHTS OH
44130-8361
US

IV. Provider business mailing address

6700 WEST SNOWVILLE ROAD
BRECKSVILLE OH
44141-3285
US

V. Phone/Fax

Practice location:
  • Phone: 216-282-1491
  • Fax: 216-920-9592
Mailing address:
  • Phone: 216-485-5788
  • Fax: 216-920-9593

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number30-025210
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number30-025207
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number30-015265
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State

VIII. Authorized Official

Name: GAIL SANDISH
Title or Position: ADMIN ASST
Credential:
Phone: 216-485-5788