Healthcare Provider Details

I. General information

NPI: 1467797134
Provider Name (Legal Business Name): MACLEAN & JUNGDAHL, DMD, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2012
Last Update Date: 12/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1035 SUMMITT DR
MIDDLETOWN OH
45042-3464
US

IV. Provider business mailing address

1035 SUMMITT DR
MIDDLETOWN OH
45042-3464
US

V. Phone/Fax

Practice location:
  • Phone: 513-424-5339
  • Fax: 513-422-1646
Mailing address:
  • Phone: 513-424-5339
  • Fax: 513-422-1646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number20757
License Number StateOH

VIII. Authorized Official

Name: DOUGLAS C MACLEAN
Title or Position: SECRETARY TREASURER
Credential: DMD
Phone: 513-424-5339