Provider Demographics
NPI:1245391424
Name:CWRU FACULTY DENTAL PRACTICE
Entity Type:Organization
Organization Name:CWRU FACULTY DENTAL PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:DAVOL
Authorized Official - Last Name:CHAPMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MED
Authorized Official - Phone:216-368-0592
Mailing Address - Street 1:10900 EUCLID AVENUE
Mailing Address - Street 2:SCHOOL OF DENTAL MEDICINE/FACULTY PRACTICE
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44106-4905
Mailing Address - Country:US
Mailing Address - Phone:216-368-0592
Mailing Address - Fax:216-368-6310
Practice Address - Street 1:2123 ABINGTON ROAD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-4905
Practice Address - Country:US
Practice Address - Phone:216-368-0592
Practice Address - Fax:216-368-6310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-001501223E0200X
OH30-188471223G0001X
OH30-202151223G0001X
OH30-0220761223P0300X
OH30-001941223P0700X
OH30-001491223X0400X
OH30-0217851223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
Not Answered1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Not Answered1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
Not Answered1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
Not Answered1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty