Healthcare Provider Details

I. General information

NPI: 1538380662
Provider Name (Legal Business Name): WESTERN LAKE ERIE OMS LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 07/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5690 MONROE ST
SYLVANIA OH
43560-2736
US

IV. Provider business mailing address

5690 MONROE ST
SYLVANIA OH
43560-2736
US

V. Phone/Fax

Practice location:
  • Phone: 419-479-3939
  • Fax: 419-479-3933
Mailing address:
  • Phone: 419-479-3939
  • Fax: 419-479-3933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: STEPHEN MARK SHALL
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 419-479-3939