Provider Demographics
NPI:1639622723
Name:NORTHWEST OHIO PERIODONTICS, BRIAN M. ROY D.D.S., M.S., LLC
Entity Type:Organization
Organization Name:NORTHWEST OHIO PERIODONTICS, BRIAN M. ROY D.D.S., M.S., LLC
Other - Org Name:NORTHWEST OHIO PERIODONTICS, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:ROY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:419-865-7692
Mailing Address - Street 1:7100 SPRING MEADOWS W DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:HOLLAND
Mailing Address - State:OH
Mailing Address - Zip Code:43528-7202
Mailing Address - Country:US
Mailing Address - Phone:419-865-7692
Mailing Address - Fax:419-865-9731
Practice Address - Street 1:7100 SPRING MEADOWS W DR
Practice Address - Street 2:SUITE A
Practice Address - City:HOLLAND
Practice Address - State:OH
Practice Address - Zip Code:43528-7202
Practice Address - Country:US
Practice Address - Phone:419-865-7692
Practice Address - Fax:419-865-9731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-26
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.247911223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty