Provider Demographics
NPI:1659723534
Name:INNOVATIVE DENTAL
Entity Type:Organization
Organization Name:INNOVATIVE DENTAL
Other - Org Name:HILLS INNOVATIVE DENTAL INC
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:R
Authorized Official - Last Name:HILLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-721-0500
Mailing Address - Street 1:13922 CEDAR RD STE 3
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44118-3204
Mailing Address - Country:US
Mailing Address - Phone:216-721-0500
Mailing Address - Fax:216-371-5775
Practice Address - Street 1:13922 CEDAR RD STE 3
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44118-3204
Practice Address - Country:US
Practice Address - Phone:216-721-0500
Practice Address - Fax:216-371-5775
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-05
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental