Provider Demographics
NPI:1992197883
Name:OHIO DENTAL PROFESSIONALS, DELISLE, PC
Entity Type:Organization
Organization Name:OHIO DENTAL PROFESSIONALS, DELISLE, PC
Other - Org Name:EAST BROAD FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:KENDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8312
Mailing Address - Street 1:8086 E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-8024
Mailing Address - Country:US
Mailing Address - Phone:614-328-9661
Mailing Address - Fax:
Practice Address - Street 1:8086 E BROAD ST
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068
Practice Address - Country:US
Practice Address - Phone:614-328-9661
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OHIO DENTAL PROFESSIONALS, DELISLE, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-03-02
Last Update Date:2015-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300243111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty