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General NPI Number Information
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NPI Number | 1790233971
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Entity Type | Organization
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Legal Business Name | FAMILY DENTISTRY ON THE SQUARE, INC
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Dates
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Enumeration Date | 09/15/2016
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Last Update Date | 09/15/2016
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Provider Practice Location Address
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Address Line | 111 MAIN ST
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City | WADSWORTH
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State | OH
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Zip | 44281-1433
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Country | US
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Telephone | 330-336-5788
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Fax | 330-334-1425
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Provider Business Mailing Address
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Address Line | 111 MAIN ST
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City | WADSWORTH
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State | OH
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Zip | 44281-1433
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Country | US
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Telephone | 330-336-5788
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Fax | 330-334-1425
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Authorized Official
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Title or Position | OWNER/DENTIST
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Name | ROBERT R GUTHRIE
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Credential | D.D.S.
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Telephone | 330-336-5788
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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 | 30-16242
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License Number State | OH
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