Provider Demographics
NPI:1801387972
Name:OHIO DENTAL PROFESSIONALS, DELISLE, P.C.
Entity Type:Organization
Organization Name:OHIO DENTAL PROFESSIONALS, DELISLE, P.C.
Other - Org Name:ADVANCED DENTAL CARE OF STREETSBORO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING TEAM LEAD
Authorized Official - Prefix:
Authorized Official - First Name:CASSANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8972
Mailing Address - Street 1:9305 MARKET SQUARE DR
Mailing Address - Street 2:
Mailing Address - City:STREETSBORO
Mailing Address - State:OH
Mailing Address - Zip Code:44241-5294
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9305 MARKET SQUARE DR
Practice Address - Street 2:
Practice Address - City:STREETSBORO
Practice Address - State:OH
Practice Address - Zip Code:44241-5294
Practice Address - Country:US
Practice Address - Phone:330-422-0011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OHIO DENTAL PROFESSIONALS, DELISLE, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-05-24
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty