Provider Demographics
NPI:1508419938
Name:CUSTOM DENTAL OF OTTAWA, PA
Entity Type:Organization
Organization Name:CUSTOM DENTAL OF OTTAWA, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:RENE
Authorized Official - Middle Name:
Authorized Official - Last Name:RODGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-227-6100
Mailing Address - Street 1:2030 S PRINCETON ST
Mailing Address - Street 2:
Mailing Address - City:OTTAWA
Mailing Address - State:KS
Mailing Address - Zip Code:66067
Mailing Address - Country:US
Mailing Address - Phone:785-521-3737
Mailing Address - Fax:
Practice Address - Street 1:2030 S PRINCETON ST
Practice Address - Street 2:
Practice Address - City:OTTAWA
Practice Address - State:KS
Practice Address - Zip Code:66067
Practice Address - Country:US
Practice Address - Phone:785-521-3737
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-24
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental