Provider Demographics
NPI:1235537549
Name:WAUSEON DENTAL GROUP L.L.C.
Entity Type:Organization
Organization Name:WAUSEON DENTAL GROUP L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:S
Authorized Official - Last Name:PELOK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:419-337-2391
Mailing Address - Street 1:229 N FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:WAUSEON
Mailing Address - State:OH
Mailing Address - Zip Code:43567-1265
Mailing Address - Country:US
Mailing Address - Phone:419-337-2391
Mailing Address - Fax:419-335-0700
Practice Address - Street 1:229 N FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:WAUSEON
Practice Address - State:OH
Practice Address - Zip Code:43567-1265
Practice Address - Country:US
Practice Address - Phone:419-337-2391
Practice Address - Fax:419-335-0700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-18
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300199201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty