Provider Demographics
NPI:1225447709
Name:MAHONING AVENUE DENTAL HEALTH CENTER MICHAEL CRITES DDS INC
Entity Type:Organization
Organization Name:MAHONING AVENUE DENTAL HEALTH CENTER MICHAEL CRITES DDS INC
Other - Org Name:JAMBOREE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REVENUE CYCLE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNAFER
Authorized Official - Middle Name:
Authorized Official - Last Name:CORRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-931-3949
Mailing Address - Street 1:3353 MAHONING AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44509-2617
Mailing Address - Country:US
Mailing Address - Phone:330-792-9600
Mailing Address - Fax:
Practice Address - Street 1:3353 MAHONING AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44509-2617
Practice Address - Country:US
Practice Address - Phone:330-792-9600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-08
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300195011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty