Provider Demographics
NPI:1982827085
Name:FIRESTONE FAMILY DENTAL INC
Entity Type:Organization
Organization Name:FIRESTONE FAMILY DENTAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:WELLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:330-773-7282
Mailing Address - Street 1:275 E WATERLOO RD
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44319-1238
Mailing Address - Country:US
Mailing Address - Phone:330-773-7282
Mailing Address - Fax:330-773-7114
Practice Address - Street 1:275 E WATERLOO RD
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44319-1238
Practice Address - Country:US
Practice Address - Phone:330-773-7282
Practice Address - Fax:330-773-7114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300183021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH30018302OtherLICENSE NUMBER