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General NPI Number Information
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NPI Number | 1689070351
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Entity Type | Organization
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Legal Business Name | VILLAGE DENTAL GROUP LLC
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Dates
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Enumeration Date | 11/07/2014
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Last Update Date | 11/07/2014
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Provider Practice Location Address
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Address Line | 1151 S HIGH ST
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City | COLUMBUS
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State | OH
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Zip | 43206-3434
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Country | US
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Telephone | 614-445-8800
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Fax |
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Provider Business Mailing Address
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Address Line | 1151 S HIGH ST
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City | COLUMBUS
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State | OH
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Zip | 43206-3434
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Country | US
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Telephone | 614-445-8800
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Fax |
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Authorized Official
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Title or Position | DENTIST/OWNER
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Name | SAM LATIF
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Credential | DMD
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Telephone | 614-445-8800
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 017747
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License Number State | OH
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