Provider Demographics
NPI:1992369896
Name:UTTERBACK DENTAL GROUP, INC
Entity Type:Organization
Organization Name:UTTERBACK DENTAL GROUP, INC
Other - Org Name:UTTERBACK DENTAL GROUP, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:UTTERBACK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:330-821-6603
Mailing Address - Street 1:2414 WHIPPLE AVE NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44708-1514
Mailing Address - Country:US
Mailing Address - Phone:330-479-0072
Mailing Address - Fax:
Practice Address - Street 1:2414 WHIPPLE AVE NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44708-1514
Practice Address - Country:US
Practice Address - Phone:330-479-0072
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-25
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty