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General NPI Number Information
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NPI Number | 1790342863
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Entity Type | Individual
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Provider Name | LEA VAN KLINE-SHIVERS DMD
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Gender | Female
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Dates
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Enumeration Date | 05/23/2019
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Last Update Date | 07/08/2019
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Provider Practice Location Address
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Address Line | 1044 BELMONT AVE
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City | YOUNGSTOWN
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State | OH
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Zip | 44504-1006
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Country | US
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Telephone | 330-480-2994
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Fax |
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Provider Business Mailing Address
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Address Line | 247 UPLAND AVE
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City | YOUNGSTOWN
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State | OH
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Zip | 44504-1848
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Country | US
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Telephone | 330-261-2434
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | RES.004113
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License Number State | OH
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