Provider Demographics
NPI:1851308316
Name:DEDARIO OPTICAL CENTER
Entity Type:Organization
Organization Name:DEDARIO OPTICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, LDO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:DEDARIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-278-9700
Mailing Address - Street 1:6550 N. MAIUN STREET
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45415-2854
Mailing Address - Country:US
Mailing Address - Phone:937-278-9700
Mailing Address - Fax:937-278-4661
Practice Address - Street 1:6550 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45415-2854
Practice Address - Country:US
Practice Address - Phone:937-278-9700
Practice Address - Fax:937-278-4661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1487SC156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHDE9217382Medicare ID - Type Unspecified