Provider Demographics
NPI:1023416294
Name:SOUTH VIENNA FAMILY DENTAL
Entity type:Organization
Organization Name:SOUTH VIENNA FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IRFAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:937-568-3302
Mailing Address - Street 1:8490 E NATIONAL RD
Mailing Address - Street 2:PO BOX 215
Mailing Address - City:SOUTH VIENNA
Mailing Address - State:OH
Mailing Address - Zip Code:45369-9707
Mailing Address - Country:US
Mailing Address - Phone:937-568-3302
Mailing Address - Fax:937-568-3304
Practice Address - Street 1:8490 E NATIONAL RD
Practice Address - Street 2:
Practice Address - City:SOUTH VIENNA
Practice Address - State:OH
Practice Address - Zip Code:45369-9707
Practice Address - Country:US
Practice Address - Phone:937-568-3302
Practice Address - Fax:937-568-3304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-19
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-0228871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty