Provider Demographics
NPI:1043325368
Name:JON B. DOVE, D.D.S. A PROFESSIONAL LLC
Entity Type:Organization
Organization Name:JON B. DOVE, D.D.S. A PROFESSIONAL LLC
Other - Org Name:PERRYSBURG FAMILY DENTISTRY
Other - Org Type:Other Name
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:DOVE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:419-872-9191
Mailing Address - Street 1:139 W INDIANA AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-1583
Mailing Address - Country:US
Mailing Address - Phone:419-872-9191
Mailing Address - Fax:419-872-9590
Practice Address - Street 1:139 W INDIANA AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-1583
Practice Address - Country:US
Practice Address - Phone:419-872-9191
Practice Address - Fax:419-872-9590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH19539122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH803897OtherUNITED CONCORDIA PROVIDER