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General NPI Number Information
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NPI Number | 1144757469
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Entity Type | Organization
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Legal Business Name | NORTHWEST OHIO DENTAL SPECILITY CENTER,LLC
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Dates
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Enumeration Date | 05/17/2017
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Last Update Date | 06/12/2017
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Provider Practice Location Address
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Address Line | 610 BROADMOOR AVE
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City | NAPOLEON
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State | OH
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Zip | 43545-1288
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Country | US
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Telephone | 419-592-5854
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Fax | 419-930-6500
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Provider Business Mailing Address
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Address Line | 610 BROADMOOR AVE
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City | NAPOLEON
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State | OH
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Zip | 43545-1288
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Country | US
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Telephone | 419-592-9956
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Fax | 419-930-6500
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Authorized Official
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Title or Position | PRACTICE ADMINISTRATOR
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Name | MRS. STACY LYNN FRESHOUR
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Credential |
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Telephone | 419-592-9956
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 30022360
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License Number State | OH
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