Provider Demographics
NPI:1790233971
Name:FAMILY DENTISTRY ON THE SQUARE, INC
Entity Type:Organization
Organization Name:FAMILY DENTISTRY ON THE SQUARE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:R
Authorized Official - Last Name:GUTHRIE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:330-336-5788
Mailing Address - Street 1:111 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WADSWORTH
Mailing Address - State:OH
Mailing Address - Zip Code:44281-1433
Mailing Address - Country:US
Mailing Address - Phone:330-336-5788
Mailing Address - Fax:330-334-1425
Practice Address - Street 1:111 MAIN ST
Practice Address - Street 2:
Practice Address - City:WADSWORTH
Practice Address - State:OH
Practice Address - Zip Code:44281-1433
Practice Address - Country:US
Practice Address - Phone:330-336-5788
Practice Address - Fax:330-334-1425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-15
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-16242122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0407018Medicaid