Provider Demographics
NPI:1629185046
Name:DRS. DETWILER & GANNON, INC.
Entity Type:Organization
Organization Name:DRS. DETWILER & GANNON, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:DETWILER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:419-874-3129
Mailing Address - Street 1:880 COMMERCE DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-5240
Mailing Address - Country:US
Mailing Address - Phone:419-874-3129
Mailing Address - Fax:419-874-5007
Practice Address - Street 1:880 COMMERCE DR
Practice Address - Street 2:SUITE A
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-5240
Practice Address - Country:US
Practice Address - Phone:419-874-3129
Practice Address - Fax:419-874-5007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty