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General NPI Number Information
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NPI Number | 1942694583
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Entity Type | Organization
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Legal Business Name | SOUTH DAYTON ORAL & MAXILLOFACIAL SURGERY INC
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Dates
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Enumeration Date | 03/20/2015
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Last Update Date | 03/20/2015
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Provider Practice Location Address
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Address Line | 7325 FAR HILLS AVE
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City | DAYTON
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State | OH
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Zip | 45459-4415
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Country | US
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Telephone | 937-439-1606
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Fax |
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Provider Business Mailing Address
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Address Line | 7325 FAR HILLS AVE
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City | DAYTON
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State | OH
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Zip | 45459-4415
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | TRENT TUCKER
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Credential | DDS, MD
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Telephone | 419-680-0023
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 30-02437
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License Number State | OH
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