Provider Demographics
NPI:1124418892
Name:SUMMIT DENTAL HEALTH - BLONDO LLC
Entity Type:Organization
Organization Name:SUMMIT DENTAL HEALTH - BLONDO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:COREZ
Authorized Official - Middle Name:
Authorized Official - Last Name:LOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-254-8500
Mailing Address - Street 1:PO BOX 437169
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40253-7169
Mailing Address - Country:US
Mailing Address - Phone:502-254-8500
Mailing Address - Fax:
Practice Address - Street 1:2005 N 90TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68134-6002
Practice Address - Country:US
Practice Address - Phone:402-799-1016
Practice Address - Fax:402-513-2745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-02
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty