Provider Demographics
NPI:1144757469
Name:NORTHWEST OHIO DENTAL SPECILITY CENTER,LLC
Entity Type:Organization
Organization Name:NORTHWEST OHIO DENTAL SPECILITY CENTER,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:STACY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:FRESHOUR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-592-9956
Mailing Address - Street 1:610 BROADMOOR AVE
Mailing Address - Street 2:
Mailing Address - City:NAPOLEON
Mailing Address - State:OH
Mailing Address - Zip Code:43545-1288
Mailing Address - Country:US
Mailing Address - Phone:419-592-9956
Mailing Address - Fax:419-930-6500
Practice Address - Street 1:610 BROADMOOR AVE
Practice Address - Street 2:
Practice Address - City:NAPOLEON
Practice Address - State:OH
Practice Address - Zip Code:43545-1288
Practice Address - Country:US
Practice Address - Phone:419-592-5854
Practice Address - Fax:419-930-6500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-17
Last Update Date:2017-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300223601223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty