Provider Demographics
NPI:1922610203
Name:EAST COLUMBUS PERIODONTICS LLC
Entity Type:Organization
Organization Name:EAST COLUMBUS PERIODONTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:C
Authorized Official - Last Name:STONER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:614-889-8222
Mailing Address - Street 1:5152 BLAZER PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017-7323
Mailing Address - Country:US
Mailing Address - Phone:614-889-8222
Mailing Address - Fax:614-889-6067
Practice Address - Street 1:5180 E MAIN ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-2436
Practice Address - Country:US
Practice Address - Phone:614-864-2561
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-19
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH30020951OtherLICENSE