Provider Demographics
NPI:1134467145
Name:ARCH CITY DENTAL, LLC
Entity Type:Organization
Organization Name:ARCH CITY DENTAL, LLC
Other - Org Name:NORTHEAST FAMILY DENTAL, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:C
Authorized Official - Last Name:BALOY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:614-891-7075
Mailing Address - Street 1:6343 PRESIDENTIAL GATEWAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43231
Mailing Address - Country:US
Mailing Address - Phone:614-891-7075
Mailing Address - Fax:614-891-6033
Practice Address - Street 1:6343 PRESIDENTIAL GATEWAY
Practice Address - Street 2:SUITE 100
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43231
Practice Address - Country:US
Practice Address - Phone:614-891-7075
Practice Address - Fax:614-891-6033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-25
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH156841223G0001X
OH207151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty