Provider Demographics
NPI:1598802571
Name:LAWRENCE COUNTY DENTAL SEALANT PROGRAM
Entity Type:Organization
Organization Name:LAWRENCE COUNTY DENTAL SEALANT PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERINTENDENT
Authorized Official - Prefix:
Authorized Official - First Name:HAROLD
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-532-4223
Mailing Address - Street 1:111 S 4TH ST
Mailing Address - Street 2:THIRD FLOOR COURTHOUSE
Mailing Address - City:IRONTON
Mailing Address - State:OH
Mailing Address - Zip Code:45638-1522
Mailing Address - Country:US
Mailing Address - Phone:740-532-4223
Mailing Address - Fax:
Practice Address - Street 1:111 S 4TH ST
Practice Address - Street 2:THIRD FLOOR COURTHOUSE
Practice Address - City:IRONTON
Practice Address - State:OH
Practice Address - Zip Code:45638-1522
Practice Address - Country:US
Practice Address - Phone:740-532-4223
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH174041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2461545Medicaid