Provider Demographics
NPI:1619086717
Name:JACK D CASTILLA LLC
Entity Type:Organization
Organization Name:JACK D CASTILLA LLC
Other - Org Name:MID OHIO DENTAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:D
Authorized Official - Last Name:CASTILLA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:614-279-9204
Mailing Address - Street 1:1206 W BROAD ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43222
Mailing Address - Country:US
Mailing Address - Phone:614-279-9204
Mailing Address - Fax:614-279-9208
Practice Address - Street 1:1206 W BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43222
Practice Address - Country:US
Practice Address - Phone:614-279-9204
Practice Address - Fax:614-279-9208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2013-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30016727122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9180566OtherMOLINA HEALTH
OH2210039Medicaid
OH9180566OtherMOLINA HEALTH