Provider Demographics
NPI:1154502557
Name:BAYSIDE FAMILY DENTISTRY
Entity Type:Organization
Organization Name:BAYSIDE FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DELBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:419-729-3974
Mailing Address - Street 1:4851 N SUMMIT ST
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43611-2870
Mailing Address - Country:US
Mailing Address - Phone:419-729-3974
Mailing Address - Fax:419-729-9476
Practice Address - Street 1:4851 N SUMMIT ST
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43611-2870
Practice Address - Country:US
Practice Address - Phone:419-729-3974
Practice Address - Fax:419-729-9476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-14
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH021619122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty