Provider Demographics
NPI:1609041698
Name:MARION FAMILY DENTAL
Entity Type:Organization
Organization Name:MARION FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAITH
Authorized Official - Middle Name:A
Authorized Official - Last Name:SAWALHA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:740-387-5188
Mailing Address - Street 1:716 S PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-6278
Mailing Address - Country:US
Mailing Address - Phone:740-382-3464
Mailing Address - Fax:
Practice Address - Street 1:716 S PROSPECT ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-6278
Practice Address - Country:US
Practice Address - Phone:740-382-3464
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2762078Medicaid