Provider Demographics
NPI:1952077166
Name:OHIO DENTAL PROFESSIONALS, DELISLE, P.C.
Entity Type:Organization
Organization Name:OHIO DENTAL PROFESSIONALS, DELISLE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:TABATHA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEMKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-6078
Mailing Address - Street 1:792 EASTGATE SOUTH DR STE 250
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45245-1563
Mailing Address - Country:US
Mailing Address - Phone:513-746-8228
Mailing Address - Fax:
Practice Address - Street 1:792 EASTGATE SOUTH DR STE 250
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45245-1563
Practice Address - Country:US
Practice Address - Phone:513-746-8228
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OHIO DENTAL PROFESSIONALS, DELISLE, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-08-18
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty