Healthcare Provider Details

I. General information

NPI: 1972624922
Provider Name (Legal Business Name): MOGADORE FAMILY DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 S CLEVELAND AVE
MOGADORE OH
44260-1514
US

IV. Provider business mailing address

11 S CLEVELAND AVE
MOGADORE OH
44260-1514
US

V. Phone/Fax

Practice location:
  • Phone: 330-628-3017
  • Fax: 330-628-1436
Mailing address:
  • Phone: 330-628-3017
  • Fax: 330-628-1436

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number30.018523
License Number StateOH

VIII. Authorized Official

Name: LOUIS W KONSTAN
Title or Position: DENTIST
Credential: D.D.S.
Phone: 330-628-3017