Healthcare Provider Details

I. General information

NPI: 1609323831
Provider Name (Legal Business Name): COMPLETE DENTAL CARE OF SHADYSIDE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2016
Last Update Date: 09/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3775 CENTRAL AVE
SHADYSIDE OH
43947-1344
US

IV. Provider business mailing address

2700 SUNSET BLVD
STEUBENVILLE OH
43952-1158
US

V. Phone/Fax

Practice location:
  • Phone: 740-676-2604
  • Fax: 740-676-2604
Mailing address:
  • Phone: 740-264-6811
  • Fax: 740-264-6812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number30.016390
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number30.024551
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number30.24884
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number30.023979
License Number StateOH

VIII. Authorized Official

Name: ARMANDA LESTER
Title or Position: OFFICE MANAGER
Credential:
Phone: 740-485-0309