Healthcare Provider Details

I. General information

NPI: 1902818479
Provider Name (Legal Business Name): IRA S LEVENSON D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1502 COLUMBUS AVE
WASHINGTON COURT HOUSE OH
43160-1767
US

IV. Provider business mailing address

147 PINCKNEY ST
CIRCLEVILLE OH
43113-1627
US

V. Phone/Fax

Practice location:
  • Phone: 740-335-8877
  • Fax:
Mailing address:
  • Phone: 740-474-8558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number30018442
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: