Healthcare Provider Details

I. General information

NPI: 1245691492
Provider Name (Legal Business Name): DAVID R. BACKUS DDS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2016
Last Update Date: 03/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4720 JACKMAN RD SUITE A
TOLEDO OH
43612-2077
US

IV. Provider business mailing address

4720 JACKMAN RD SUITE A
TOLEDO OH
43612-2077
US

V. Phone/Fax

Practice location:
  • Phone: 419-476-1484
  • Fax: 419-476-6914
Mailing address:
  • Phone: 419-476-1484
  • Fax: 419-476-6914

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number18187
License Number StateOH

VIII. Authorized Official

Name: AMY J BACKUS
Title or Position: TREASURER
Credential:
Phone: 419-476-1484