Provider Demographics
NPI:1164537684
Name:OHIO STATE DENTAL FACULTY PRACTICE INC
Entity Type:Organization
Organization Name:OHIO STATE DENTAL FACULTY PRACTICE INC
Other - Org Name:OHIO STATE DENTAL FACULTY PRACTICE INC- JOHN R KALMAR, DMD, PHD
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:MURRAY
Authorized Official - Last Name:MYERS
Authorized Official - Suffix:
Authorized Official - Credentials:MHHA
Authorized Official - Phone:614-688-4378
Mailing Address - Street 1:305 W 12TH AVE
Mailing Address - Street 2:2301 POSTLE HALL
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43210-1267
Mailing Address - Country:US
Mailing Address - Phone:614-292-1472
Mailing Address - Fax:614-688-3553
Practice Address - Street 1:305 W. 12TH AVENUE
Practice Address - Street 2:4TH FLOOR POSTLE HALL
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210-1267
Practice Address - Country:US
Practice Address - Phone:614-292-1472
Practice Address - Fax:614-688-3553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0799104Medicaid
OH0799104Medicaid