Provider Demographics
NPI:1083108435
Name:OHIO STREET FAMILY DENTAL GROUP, LLC
Entity type:Organization
Organization Name:OHIO STREET FAMILY DENTAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHEONA
Authorized Official - Middle Name:
Authorized Official - Last Name:KIMMEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-937-8878
Mailing Address - Street 1:5201 N ABBE RD
Mailing Address - Street 2:
Mailing Address - City:SHEFFIELD VILLAGE
Mailing Address - State:OH
Mailing Address - Zip Code:44035-1451
Mailing Address - Country:US
Mailing Address - Phone:440-937-8878
Mailing Address - Fax:
Practice Address - Street 1:406 OHIO ST
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-3925
Practice Address - Country:US
Practice Address - Phone:440-937-8878
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-19
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0200751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty