Healthcare Provider Details

I. General information

NPI: 1770524407
Provider Name (Legal Business Name): KIP OLDACRE D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1502 COLUMBUS AVE
WASHINGTON CH OH
43160-1767
US

IV. Provider business mailing address

1502 COLUMBUS AVE
WASHINGTON CH OH
43160-1767
US

V. Phone/Fax

Practice location:
  • Phone: 740-335-2821
  • Fax:
Mailing address:
  • Phone: 740-335-2821
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number17752
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: