=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770138513
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RDW2 DENTAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/08/2019
-----------------------------------------------------
Last Update Date | 08/08/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 989 N 4TH ST
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43201-3666
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-586-4160
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6327 THOMAS JEFFREY
-----------------------------------------------------
City | NEW ALBANY
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43054-5037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-586-4160
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER DENTIST
-----------------------------------------------------
Name | DR. ROBERT DONALD WOOD II
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 615-586-4160
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------