=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275009417
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DENT-AL SMILES OF EATON,LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/15/2018
-----------------------------------------------------
Last Update Date | 10/15/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1024 N BARRON ST
-----------------------------------------------------
City | EATON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45320-1053
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-456-6228
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1115 HICKS BLVD STE 3
-----------------------------------------------------
City | FAIRFIELD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45014-2867
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-795-7706
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ALVARO R LAZO
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 412-779-4235
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------