Provider Demographics
NPI:1619091568
Name:SOUTHERN OHIO ENDODONTICS CLINIC, LLC
Entity Type:Organization
Organization Name:SOUTHERN OHIO ENDODONTICS CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DERON
Authorized Official - Middle Name:
Authorized Official - Last Name:REISMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-774-6230
Mailing Address - Street 1:31 N PLAZA BLVD
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-1759
Mailing Address - Country:US
Mailing Address - Phone:740-774-6230
Mailing Address - Fax:740-774-6326
Practice Address - Street 1:31 N PLAZA BLVD
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-1759
Practice Address - Country:US
Practice Address - Phone:740-774-6230
Practice Address - Fax:740-774-6326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH201571223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty