MEDICARE: GID ORTHODONTICS LLC

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	NONE	OTHER		NONE

General Provider Information

NPI Number	:	1679103865
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GID ORTHODONTICS LLC

Provider Business Mailing Address
First Line	:	4845 RIALTO RD STE A
Second Line	:
City	:	WEST CHESTER
State	:	OH
Zip	:	45069-2910
Country	:	US
Telephone Number	:	513-772-6500
Fax Number	:	513-772-2002

Provider Business Practice Location Address
First Line	:	6876 CINCINNATI DAYTON RD STE 104
Second Line	:
City	:	LIBERTY TOWNSHIP
State	:	OH
Zip	:	45044-8898
Country	:	US
Telephone Number	:	513-772-6500
Fax Number	:	513-772-2002

Authorized Official
Title or Position	:	PARTNER
Name	:	KEVIN J ISON
Credential	:	DMD, MS
Telephone Number	:	513-772-6500

Provider Enumeration Date	:	01/16/2020
Last Update Date	:	02/06/2020

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Directions to “GID ORTHODONTICS LLC ” Practice Location

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