Provider Demographics
NPI:1326254111
Name:COLUMBUS PEDIATRIC DENTISTRY, P.C.
Entity Type:Organization
Organization Name:COLUMBUS PEDIATRIC DENTISTRY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:PROF
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:V
Authorized Official - Last Name:PAVLOV
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:812-376-0166
Mailing Address - Street 1:3158 N NATIONAL RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47201-3170
Mailing Address - Country:US
Mailing Address - Phone:812-376-0166
Mailing Address - Fax:
Practice Address - Street 1:3158 N NATIONAL RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-3170
Practice Address - Country:US
Practice Address - Phone:812-376-0166
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty