Provider Demographics
NPI:1093837304
Name:EASTSIDE FAMILY DENTAL
Entity Type:Organization
Organization Name:EASTSIDE FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:B
Authorized Official - Last Name:BANCHEFSKY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:614-759-1800
Mailing Address - Street 1:6100 E MAIN ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213-3399
Mailing Address - Country:US
Mailing Address - Phone:614-759-1800
Mailing Address - Fax:614-759-1899
Practice Address - Street 1:6100 E MAIN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-3399
Practice Address - Country:US
Practice Address - Phone:614-759-1800
Practice Address - Fax:614-759-1899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH17299122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty