Provider Demographics
NPI:1639454804
Name:LEIDENHEIMER DENTAL GROUP
Entity Type:Organization
Organization Name:LEIDENHEIMER DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:SOCHACKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-324-3441
Mailing Address - Street 1:42707 N RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035-1054
Mailing Address - Country:US
Mailing Address - Phone:440-324-3441
Mailing Address - Fax:
Practice Address - Street 1:42707 N RIDGE RD
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-1054
Practice Address - Country:US
Practice Address - Phone:440-324-3441
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-19
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0015325Medicaid
OH2203538Medicaid
OH2093907Medicaid
OH2825410Medicaid