Provider Demographics
NPI:1225365901
Name:JUDIS ALUM CREEK DENTAL CARE
Entity Type:Organization
Organization Name:JUDIS ALUM CREEK DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:M
Authorized Official - Last Name:JUDIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:614-409-9404
Mailing Address - Street 1:4016 ALUM CREEK DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43207-5137
Mailing Address - Country:US
Mailing Address - Phone:614-409-9404
Mailing Address - Fax:614-409-2992
Practice Address - Street 1:4016 ALUM CREEK DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43207-5137
Practice Address - Country:US
Practice Address - Phone:614-409-9404
Practice Address - Fax:614-409-2992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-17
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH19680122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2039305Medicaid