=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871067504
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OLLOM COMMUNITY DENTAL, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2019
-----------------------------------------------------
Last Update Date | 11/30/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1702 ALLENTOWN RD
-----------------------------------------------------
City | LIMA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45805-1845
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-222-0693
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1702 ALLENTOWN RD
-----------------------------------------------------
City | LIMA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45805-1845
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-222-0693
-----------------------------------------------------
Fax | 419-879-6478
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF OPERATIONS
-----------------------------------------------------
Name | JANE ANN CAMPBELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 419-228-4036
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------