Provider Demographics
NPI:1093787624
Name:MECKLER DENTAL PROVIDERS (OLMSTED), INC
Entity Type:Organization
Organization Name:MECKLER DENTAL PROVIDERS (OLMSTED), INC
Other - Org Name:DENTALWORKS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUPERVISOR, CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:STAUTIHAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-584-1673
Mailing Address - Street 1:PO BOX 860036
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55486-0036
Mailing Address - Country:US
Mailing Address - Phone:440-734-6500
Mailing Address - Fax:216-584-1004
Practice Address - Street 1:4710 GREAT NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:NORTH OLMSTED
Practice Address - State:OH
Practice Address - Zip Code:44070-3427
Practice Address - Country:US
Practice Address - Phone:440-716-6939
Practice Address - Fax:216-584-1004
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTALONE PARTNERS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-02-07
Last Update Date:2018-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
122300000X, 1223E0200X, 1223G0001X, 1223P0221X, 1223P0300X, 1223P0700X, 1223S0112X, 1223X0400X
OH30.0179941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty