Provider Demographics
NPI:1952035859
Name:CORCORAN PRIVITERA FAMILY DENTAL LLC
Entity Type:Organization
Organization Name:CORCORAN PRIVITERA FAMILY DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:M
Authorized Official - Last Name:PRIVITERA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:440-415-2334
Mailing Address - Street 1:415 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:PIKETON
Mailing Address - State:OH
Mailing Address - Zip Code:45661-9111
Mailing Address - Country:US
Mailing Address - Phone:440-415-2334
Mailing Address - Fax:
Practice Address - Street 1:15 SHAKER RUN RD
Practice Address - Street 2:
Practice Address - City:PEEBLES
Practice Address - State:OH
Practice Address - Zip Code:45660-9401
Practice Address - Country:US
Practice Address - Phone:937-587-3903
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-15
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1376586669OtherNPI
1669037529OtherNPI
OH0349182Medicaid
OH0521224Medicaid
OH0349186Medicaid
1326603283OtherNPI