Provider Demographics
NPI:1114441417
Name:CRESTA DENTAL IMPLANTS LLC
Entity Type:Organization
Organization Name:CRESTA DENTAL IMPLANTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN ASST
Authorized Official - Prefix:
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDISH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-485-5788
Mailing Address - Street 1:6700 W SNOWVILLE RD
Mailing Address - Street 2:
Mailing Address - City:BRECKSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44141-3285
Mailing Address - Country:US
Mailing Address - Phone:216-485-5788
Mailing Address - Fax:
Practice Address - Street 1:7081 PEARL ROAD
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44130-8361
Practice Address - Country:US
Practice Address - Phone:216-282-1491
Practice Address - Fax:216-920-9592
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-28
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-0252071223E0200X
OH30-0252101223E0200X
OH30-0152651223G0001X
OH30-0252091223P0300X
1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty