Provider Demographics
NPI:1104019587
Name:SEDON DENTAL PROVIDERS (MEDINA), INC.
Entity Type:Organization
Organization Name:SEDON DENTAL PROVIDERS (MEDINA), INC.
Other - Org Name:DENTALWORKS OF MEDINA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:NITTINGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-755-0816
Mailing Address - Street 1:7160 DALLAS PKWY STE 400
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-7111
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5014 GRANDE SHOPS AVE
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256
Practice Address - Country:US
Practice Address - Phone:330-764-9290
Practice Address - Fax:216-584-1079
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTALONE PARTNERS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-20
Last Update Date:2017-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
122300000X, 1223P0221X, 1223P0300X, 1223P0700X, 1223X0400X
OH30.0173991223G0001X
OH30.0232581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Single Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty