Provider Demographics
NPI:1033296553
Name:PAINESVILLE DENTAL GROUP
Entity Type:Organization
Organization Name:PAINESVILLE DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER/MEMBER DDS
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:V
Authorized Official - Last Name:PATRIARCA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:440-354-2183
Mailing Address - Street 1:301 CENTER ST.
Mailing Address - Street 2:SUITE 5
Mailing Address - City:CHARDON
Mailing Address - State:OH
Mailing Address - Zip Code:44024
Mailing Address - Country:US
Mailing Address - Phone:440-286-2474
Mailing Address - Fax:440-286-2476
Practice Address - Street 1:128 MENTOR AVE
Practice Address - Street 2:
Practice Address - City:PAINESVILLE
Practice Address - State:OH
Practice Address - Zip Code:44077
Practice Address - Country:US
Practice Address - Phone:440-354-2183
Practice Address - Fax:440-354-0811
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PAINESVILLE DENTAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-01
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty