Healthcare Provider Details

I. General information

NPI: 1093958597
Provider Name (Legal Business Name): CHARLES ROGER ZODY II D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2009
Last Update Date: 04/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 RIVERSIDE DR SUITE 150
UPPER ARLINGTON OH
43221-1738
US

IV. Provider business mailing address

3300 RIVERSIDE DR SUITE 150
UPPER ARLINGTON OH
43221-1738
US

V. Phone/Fax

Practice location:
  • Phone: 614-451-0651
  • Fax: 614-451-6151
Mailing address:
  • Phone: 614-451-0651
  • Fax: 614-451-6151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number30-01-9272
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: