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General NPI Number Information
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NPI Number | 1780079038
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Entity Type | Organization
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Legal Business Name | BEREA FAMILY DENTAL
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Dates
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Enumeration Date | 04/03/2015
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Last Update Date | 04/03/2015
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Provider Practice Location Address
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Address Line | 20 S LIMESTONE ST SUITE110
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City | SPRINGFIELD
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State | OH
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Zip | 45502-2219
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Country | US
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Telephone | 937-322-7832
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Fax |
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Provider Business Mailing Address
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Address Line | 359 FRONT ST
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City | BEREA
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State | OH
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Zip | 44017-1760
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Country | US
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Telephone | 440-234-2813
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Fax |
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Authorized Official
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Title or Position | PRACTICE ADMINISTRATOR
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Name | KATHY NELSON
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Credential |
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Telephone | 937-206-4080
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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 | 15902
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License Number State | OH
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