=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649491929
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KIRLOUGH FAMILY DENTISTRY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18660 BAGLEY RD BLDG I, STE 304
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44130-3483
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-234-2445
-----------------------------------------------------
Fax | 440-234-2407
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18660 BAGLEY RD BLDG I, STE 304
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44130-3483
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-234-2445
-----------------------------------------------------
Fax | 440-234-2407
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JON P. KIRLOUGH
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 440-234-2445
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 30-02-1224
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------