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General NPI Number Information
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NPI Number | 1356758015
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Entity Type | Organization
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Legal Business Name | HAMILTON RIVERSIDE DENTISTRY LLC
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Dates
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Enumeration Date | 07/15/2014
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Last Update Date | 12/08/2014
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Provider Practice Location Address
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Address Line | 112 N. SECOND ST
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City | HAMILTON
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State | OH
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Zip | 45011
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Country | US
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Telephone | 513-868-0200
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Fax |
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Provider Business Mailing Address
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Address Line | 112 N 2ND ST
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City | HAMILTON
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State | OH
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Zip | 45011-2702
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Country | US
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Telephone | 513-868-0200
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Fax |
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Authorized Official
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Title or Position | OPERATIONS DIRECTOR
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Name | DAVID T TANKOVICH
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Credential |
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Telephone | 513-868-0200
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 30019324
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License Number State | OH
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