Provider Demographics
NPI:1073648622
Name:DENTAL SERVICES OF OHIO
Entity Type:Organization
Organization Name:DENTAL SERVICES OF OHIO
Other - Org Name:IMMEDIADENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:WHEELER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:913-800-6952
Mailing Address - Street 1:PO BOX 11568
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66207-4268
Mailing Address - Country:US
Mailing Address - Phone:913-428-1674
Mailing Address - Fax:913-800-6967
Practice Address - Street 1:6323 TUSSING RD
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-3984
Practice Address - Country:US
Practice Address - Phone:614-863-2222
Practice Address - Fax:913-800-6967
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL SERVICES OF OHIO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-23
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
122300000X
OH22001122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2569206Medicaid