Provider Demographics
NPI:1205008828
Name:FAMILY DENTAL TEAM, INC.
Entity Type:Organization
Organization Name:FAMILY DENTAL TEAM, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:D
Authorized Official - Last Name:GEORGE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:330-376-9424
Mailing Address - Street 1:620 RIDGEWOOD XING
Mailing Address - Street 2:SUITE K
Mailing Address - City:FAIRLAWN
Mailing Address - State:OH
Mailing Address - Zip Code:44333-3531
Mailing Address - Country:US
Mailing Address - Phone:330-376-9424
Mailing Address - Fax:330-376-2298
Practice Address - Street 1:620 RIDGEWOOD XING
Practice Address - Street 2:SUITE K
Practice Address - City:FAIRLAWN
Practice Address - State:OH
Practice Address - Zip Code:44333-3531
Practice Address - Country:US
Practice Address - Phone:330-376-9424
Practice Address - Fax:330-376-2298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-25
Last Update Date:2009-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-0122281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2531148Medicaid