Provider Demographics
NPI:1649422460
Name:DARRYL L MABRA DDS &ASSOC INC
Entity Type:Organization
Organization Name:DARRYL L MABRA DDS &ASSOC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DARRYL
Authorized Official - Middle Name:LEO
Authorized Official - Last Name:MABRA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:937-324-0095
Mailing Address - Street 1:125 E WARD ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45504-2205
Mailing Address - Country:US
Mailing Address - Phone:937-324-0095
Mailing Address - Fax:
Practice Address - Street 1:125 E WARD ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45504-2205
Practice Address - Country:US
Practice Address - Phone:937-324-0095
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-13
Last Update Date:2008-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH165291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty