Provider Demographics
NPI:1225631773
Name:MOOREHEAD DENTISTRY LEBANON LLC
Entity Type:Organization
Organization Name:MOOREHEAD DENTISTRY LEBANON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:PHIL
Authorized Official - Middle Name:
Authorized Official - Last Name:MICHAEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-462-6583
Mailing Address - Street 1:1521 WALMART DR STE 501
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OH
Mailing Address - Zip Code:45036-8350
Mailing Address - Country:US
Mailing Address - Phone:513-282-6200
Mailing Address - Fax:
Practice Address - Street 1:1521 WALMART DR STE 501
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OH
Practice Address - Zip Code:45036-8350
Practice Address - Country:US
Practice Address - Phone:513-282-6200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-18
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty