Provider Demographics
NPI:1720392616
Name:OHIO DENTAL PROFESSIONALS WORKMAN, PC
Entity Type:Organization
Organization Name:OHIO DENTAL PROFESSIONALS WORKMAN, PC
Other - Org Name:MYONTARIODENTIST.COM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KENDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5100
Mailing Address - Street 1:2193 VILLAGE MALL DR
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:OH
Mailing Address - Zip Code:44906-1162
Mailing Address - Country:US
Mailing Address - Phone:419-529-9092
Mailing Address - Fax:419-529-6529
Practice Address - Street 1:2193 VILLAGE MALL DR
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OH
Practice Address - Zip Code:44906-1162
Practice Address - Country:US
Practice Address - Phone:419-529-9092
Practice Address - Fax:419-529-6529
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OHIO DENTAL PROFESSIONALS WORKMAN, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-08-03
Last Update Date:2014-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty