Provider Demographics
NPI:1538128970
Name:PEDIATRIC DENTISTRY, JOHN A. GENNANTONIO, D.D.S., INC.
Entity Type:Organization
Organization Name:PEDIATRIC DENTISTRY, JOHN A. GENNANTONIO, D.D.S., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-474-6777
Mailing Address - Street 1:7801 BEECHMONT AVE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45255-4211
Mailing Address - Country:US
Mailing Address - Phone:513-474-6777
Mailing Address - Fax:513-474-2326
Practice Address - Street 1:7801 BEECHMONT AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45255-4211
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:2006-03-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300194201223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0000896937OtherUNITED CONCORDIA GROUP ID
OH0924807Medicaid