Provider Demographics
NPI:1770825572
Name:GEM CITY DENTAL GROUP
Entity Type:Organization
Organization Name:GEM CITY DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:LOWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-938-5529
Mailing Address - Street 1:627 S EDWIN C. MOSES BLVD.
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45417-3461
Mailing Address - Country:US
Mailing Address - Phone:937-938-5529
Mailing Address - Fax:937-938-6754
Practice Address - Street 1:627 S EDWIN C. MOSES BLVD.
Practice Address - Street 2:SUITE 2A
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-3461
Practice Address - Country:US
Practice Address - Phone:937-938-5529
Practice Address - Fax:937-938-6754
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-20
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH231131223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2991722Medicaid
OH2991722Medicaid