MEDICARE: COLUMBUS PEDIATRIC DENTISTRY, P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry

General Provider Information

NPI Number	:	1326254111
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLUMBUS PEDIATRIC DENTISTRY, P.C.

Provider Business Mailing Address
First Line	:	3158 N NATIONAL RD
Second Line	:
City	:	COLUMBUS
State	:	IN
Zip	:	47201-3170
Country	:	US
Telephone Number	:	812-376-0166
Fax Number	:

Provider Business Practice Location Address
First Line	:	3158 N NATIONAL RD
Second Line	:
City	:	COLUMBUS
State	:	IN
Zip	:	47201-3170
Country	:	US
Telephone Number	:	812-376-0166
Fax Number	:

Authorized Official
Title or Position	:	C.E.O.
Name	:	PROF. MARVIN V PAVLOV
Credential	:	J.D.
Telephone Number	:	812-376-0166

Provider Enumeration Date	:	05/16/2007
Last Update Date	:	08/22/2020

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