Provider Demographics
NPI:1346351491
Name:GMN TRI-COUNTY CAC, INC.
Entity Type:Organization
Organization Name:GMN TRI-COUNTY CAC, INC.
Other - Org Name:GMN HEALTHY SMILES DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:N
Authorized Official - Last Name:WHEELDIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-732-4292
Mailing Address - Street 1:615 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:OH
Mailing Address - Zip Code:43724-1123
Mailing Address - Country:US
Mailing Address - Phone:740-732-2388
Mailing Address - Fax:740-732-2389
Practice Address - Street 1:606 WEST ST
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:OH
Practice Address - Zip Code:43724-1229
Practice Address - Country:US
Practice Address - Phone:740-732-4292
Practice Address - Fax:740-732-2389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300221371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0875601Medicaid