Provider Demographics
NPI:1013386739
Name:STREETSBORO DENTAL
Entity Type:Organization
Organization Name:STREETSBORO DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:DANCZAK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:216-280-1700
Mailing Address - Street 1:1727 STREETSBORO PLZ
Mailing Address - Street 2:
Mailing Address - City:STREETSBORO
Mailing Address - State:OH
Mailing Address - Zip Code:44241-5635
Mailing Address - Country:US
Mailing Address - Phone:330-626-3814
Mailing Address - Fax:
Practice Address - Street 1:1727 STREETSBORO PLZ
Practice Address - Street 2:
Practice Address - City:STREETSBORO
Practice Address - State:OH
Practice Address - Zip Code:44241-5635
Practice Address - Country:US
Practice Address - Phone:330-626-3814
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-23
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0246121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty