=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932461837
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RUNION DENTAL GROUP,LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2012
-----------------------------------------------------
Last Update Date | 06/15/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1110 BEECHER XING N SUITE A
-----------------------------------------------------
City | GAHANNA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43230-4564
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-775-1300
-----------------------------------------------------
Fax | 614-775-9355
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1110 BEECHER XING N SUITE A
-----------------------------------------------------
City | GAHANNA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43230-4564
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-775-1300
-----------------------------------------------------
Fax | 614-775-9355
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. SAMANTHA J NORMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 614-775-1300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 30-023280
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------