Provider Demographics
NPI:1255492054
Name:NORTH COAST JAW CENTER. LLC
Entity Type:Organization
Organization Name:NORTH COAST JAW CENTER. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:BLAKEMORE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:440-734-3131
Mailing Address - Street 1:26777 LORAIN RD
Mailing Address - Street 2:SUITE 600
Mailing Address - City:NORTH OLMSTED
Mailing Address - State:OH
Mailing Address - Zip Code:44070-3200
Mailing Address - Country:US
Mailing Address - Phone:440-734-3131
Mailing Address - Fax:440-734-3466
Practice Address - Street 1:26777 LORAIN RD
Practice Address - Street 2:SUITE 600
Practice Address - City:NORTH OLMSTED
Practice Address - State:OH
Practice Address - Zip Code:44070-3200
Practice Address - Country:US
Practice Address - Phone:440-734-3131
Practice Address - Fax:440-734-3466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty