Provider Demographics
NPI:1225395650
Name:MONTGOMERY COUNTY COURT HOUSE
Entity Type:Organization
Organization Name:MONTGOMERY COUNTY COURT HOUSE
Other - Org Name:MONTGOMERY COUNTY BOARD OF DDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUPERINTENDENT
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:A
Authorized Official - Last Name:BANKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-837-9200
Mailing Address - Street 1:5450 SALEM AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45426-1450
Mailing Address - Country:US
Mailing Address - Phone:937-837-9258
Mailing Address - Fax:937-854-0492
Practice Address - Street 1:5450 SALEM AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45426-1450
Practice Address - Country:US
Practice Address - Phone:937-837-9200
Practice Address - Fax:937-854-0492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-23
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2847012Medicaid