=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104787829
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OHIO DENTAL PROFESSIONALS, DELISLE, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2025
-----------------------------------------------------
Last Update Date | 11/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1480 CENTER RD STE D
-----------------------------------------------------
City | AVON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44011-1239
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-937-2273
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1480 CENTER RD STE D
-----------------------------------------------------
City | AVON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44011-1239
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING COORDINATOR
-----------------------------------------------------
Name | CEMYIRA MCDOUGAL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 217-764-8609
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------