Healthcare Provider Details

I. General information

NPI: 1356437214
Provider Name (Legal Business Name): MOGADORE DENTAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 SOUTH CLEVELAND AVE
MOGADORE OH
44260-1442
US

IV. Provider business mailing address

60 SOUTH CLEVELAND AVE
MOGADORE OH
44260-1442
US

V. Phone/Fax

Practice location:
  • Phone: 330-628-2424
  • Fax: 330-628-3533
Mailing address:
  • Phone: 330-628-2424
  • Fax: 330-628-3533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number30016997
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number30016592
License Number StateOH

VIII. Authorized Official

Name: DR. DENNIS JAMES NOLAN
Title or Position: OWNER PARTNER
Credential: DDS
Phone: 330-628-2424