=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578031449
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PERRY COUNTY DENTAL GROUP SOUTH ZANESVILLE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2018
-----------------------------------------------------
Last Update Date | 11/08/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2575 MAYSVILLE PIKE
-----------------------------------------------------
City | ZANESVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43701-8081
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-452-1490
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2575 MAYSVILLE PIKE
-----------------------------------------------------
City | ZANESVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43701-8081
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-452-1490
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | DR. ROBERT GRAY HAGY
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 740-452-1490
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------