Provider Demographics
NPI:1295019115
Name:MY FAMILY DENTAL
Entity Type:Organization
Organization Name:MY FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:614-759-4746
Mailing Address - Street 1:4110 BUCKEYE PKWY
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43123-8175
Mailing Address - Country:US
Mailing Address - Phone:614-539-0765
Mailing Address - Fax:614-522-6767
Practice Address - Street 1:4110 BUCKEYE PKWY
Practice Address - Street 2:
Practice Address - City:GROVE CITY
Practice Address - State:OH
Practice Address - Zip Code:43123-8175
Practice Address - Country:US
Practice Address - Phone:614-539-0765
Practice Address - Fax:614-522-6767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-11
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30022270261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1871652495OtherINDIVIDUAL NPI
OH1821011701OtherINDIVIDUAL NPI