Healthcare Provider Details

I. General information

NPI: 1114933801
Provider Name (Legal Business Name): GEORGE LEE TRASK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 10/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 NORTH RIDGE ST STE C
MONROEVILLE OH
44847-9428
US

IV. Provider business mailing address

136 NORTH RIDGE ST STE C
MONROEVILLE OH
44847-9428
US

V. Phone/Fax

Practice location:
  • Phone: 419-465-2574
  • Fax: 419-465-2598
Mailing address:
  • Phone: 419-465-2574
  • Fax: 419-465-2598

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number30018914
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: