Healthcare Provider Details

I. General information

NPI: 1538186390
Provider Name (Legal Business Name): MICHAEL M. MOTT D.D.S., LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 E BALDWIN AVE
PAULDING OH
45879-1107
US

IV. Provider business mailing address

PO BOX 359
PAULDING OH
45879-0359
US

V. Phone/Fax

Practice location:
  • Phone: 419-399-3394
  • Fax:
Mailing address:
  • Phone: 419-399-3394
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number30017678
License Number StateOH

VIII. Authorized Official

Name: DR. MICHAEL MARTIN MOTT
Title or Position: OWNER
Credential: D.D.S.
Phone: 419-399-3394