Healthcare Provider Details

I. General information

NPI: 1699236059
Provider Name (Legal Business Name): OHIO NORTH EAST HEALTH SYSTEMS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2019
Last Update Date: 03/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 GYPSY LANE MEDICAL OFFICE BLDG A
YOUNGSTOWN OH
44504-1315
US

IV. Provider business mailing address

726 WICK AVE
YOUNGSTOWN OH
44505-2827
US

V. Phone/Fax

Practice location:
  • Phone: 877-722-3303
  • Fax: 330-884-6120
Mailing address:
  • Phone: 330-747-9551
  • Fax: 330-884-6120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: RONALD DWINNELLS
Title or Position: CEO
Credential: MD
Phone: 330-747-9551