Provider Demographics
NPI:1306828215
Name:SYLVANIA ORTHODONTICS, INC.
Entity Type:Organization
Organization Name:SYLVANIA ORTHODONTICS, INC.
Other - Org Name:DRS. SIMON, HAERIAN & LUDWIG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDRE
Authorized Official - Middle Name:H
Authorized Official - Last Name:HAERIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS, FRCD, PHD
Authorized Official - Phone:419-882-1017
Mailing Address - Street 1:6407 MONROE STREET
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560
Mailing Address - Country:US
Mailing Address - Phone:419-882-1017
Mailing Address - Fax:419-882-7571
Practice Address - Street 1:6407 MONROE STREET
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560
Practice Address - Country:US
Practice Address - Phone:419-882-1017
Practice Address - Fax:419-882-7571
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-16
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH129701223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH12970OtherPROVIDER LICENSE #