Provider Demographics
NPI:1508185802
Name:JOHN A. GENNANTONIO, DDS AND KATHRYN LUBITZ STEWART, DDS, LLC
Entity Type:Organization
Organization Name:JOHN A. GENNANTONIO, DDS AND KATHRYN LUBITZ STEWART, DDS, LLC
Other - Org Name:SEA OF SMILES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS ASSISTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACI
Authorized Official - Middle Name:
Authorized Official - Last Name:CAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-474-6777
Mailing Address - Street 1:1319 NAGEL ROAD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45255
Mailing Address - Country:US
Mailing Address - Phone:513-474-6777
Mailing Address - Fax:513-474-2326
Practice Address - Street 1:1319 NAGEL RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45255-3101
Practice Address - Country:US
Practice Address - Phone:513-474-6777
Practice Address - Fax:513-474-2326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-26
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0226591223P0221X
OH30.0194201223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0924807Medicaid
OH3047410Medicaid
OH2830146Medicaid