Provider Demographics
NPI:1801041405
Name:PEDIATRIC DENTISTRY OF CENTRAL OHIO, RICHARD M. LOOCHTAN DDS, MS, LLC
Entity Type:Organization
Organization Name:PEDIATRIC DENTISTRY OF CENTRAL OHIO, RICHARD M. LOOCHTAN DDS, MS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:M
Authorized Official - Last Name:LOOCHTAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:614-863-8500
Mailing Address - Street 1:1600 CROSS CREEKS BLVD
Mailing Address - Street 2:
Mailing Address - City:PICKERINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43147
Mailing Address - Country:US
Mailing Address - Phone:614-863-8500
Mailing Address - Fax:614-863-0874
Practice Address - Street 1:1600 CROSS CREEKS BLVD
Practice Address - Street 2:
Practice Address - City:PICKERINGTON
Practice Address - State:OH
Practice Address - Zip Code:43147
Practice Address - Country:US
Practice Address - Phone:614-863-8500
Practice Address - Fax:614-863-0874
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-24
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH188801223X0400X
1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0819127OHMedicaid