Provider Demographics
NPI:1376799098
Name:FOUNDATION DENTAL, INC.
Entity Type:Organization
Organization Name:FOUNDATION DENTAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:FREDERICK
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:330-875-2200
Mailing Address - Street 1:309 S CHAPEL ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44641-1612
Mailing Address - Country:US
Mailing Address - Phone:330-875-2200
Mailing Address - Fax:330-875-2403
Practice Address - Street 1:309 S CHAPEL ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:OH
Practice Address - Zip Code:44641-1612
Practice Address - Country:US
Practice Address - Phone:330-875-2200
Practice Address - Fax:330-875-2403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-13
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA0204171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2843712Medicaid