Provider Demographics
NPI:1891137865
Name:COLUMBUS ADVANCED FAMILY DENTISTRY
Entity Type:Organization
Organization Name:COLUMBUS ADVANCED FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:PROF
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PAVLOV
Authorized Official - Suffix:
Authorized Official - Credentials:JD, MS, MBA
Authorized Official - Phone:812-603-3996
Mailing Address - Street 1:3158 N NATIONAL RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47201-3170
Mailing Address - Country:US
Mailing Address - Phone:812-603-3996
Mailing Address - Fax:812-376-0459
Practice Address - Street 1:3158 N NATIONAL RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-3170
Practice Address - Country:US
Practice Address - Phone:812-603-3996
Practice Address - Fax:812-376-0459
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COLUMBUS PEDIATRIC DENTISTRY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-07-19
Last Update Date:2013-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN13003577A1223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Single Specialty