MEDICARE: GROVE CITY PEDIATRIC DENTISTRY

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	:	1528726445
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GROVE CITY PEDIATRIC DENTISTRY

Provider Business Mailing Address
First Line	:	40 W SHORT ST
Second Line	:
City	:	WORTHINGTON
State	:	OH
Zip	:	43085-3561
Country	:	US
Telephone Number	:	402-968-2007
Fax Number	:	614-459-0883

Provider Business Practice Location Address
First Line	:	5775 HOOVER RD STE B
Second Line	:
City	:	GROVE CITY
State	:	OH
Zip	:	43123-7693
Country	:	US
Telephone Number	:	614-350-5005
Fax Number	:	614-350-5070

Authorized Official
Title or Position	:	OWNER/MEMBER
Name	:	DR. KYLE BEULKE
Credential	:	DDS
Telephone Number	:	402-968-2007

Provider Enumeration Date	:	12/08/2021
Last Update Date	:	12/08/2021

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