Healthcare Provider Details

I. General information

NPI: 1790342863
Provider Name (Legal Business Name): LEA VAN KLINE-SHIVERS DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2019
Last Update Date: 05/03/2026
Certification Date: 05/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5700 YOUNGSTOWN WARREN RD STE 107
NILES OH
44446-4707
US

IV. Provider business mailing address

4225 RUSH BLVD
YOUNGSTOWN OH
44512-1262
US

V. Phone/Fax

Practice location:
  • Phone: 330-652-3900
  • Fax:
Mailing address:
  • Phone: 330-261-2434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number30.026183
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: