Provider Demographics
NPI:1134391311
Name:NILES FAMILY DENTISTRY ASSOCIATES , INC
Entity type:Organization
Organization Name:NILES FAMILY DENTISTRY ASSOCIATES , INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ALFRED
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:SANTUCCI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:330-652-2676
Mailing Address - Street 1:827 ROBBINS AVE
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:OH
Mailing Address - Zip Code:44446-2431
Mailing Address - Country:US
Mailing Address - Phone:330-652-2676
Mailing Address - Fax:
Practice Address - Street 1:827 ROBBINS AVE
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:OH
Practice Address - Zip Code:44446-2431
Practice Address - Country:US
Practice Address - Phone:330-652-2676
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-28
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH18923122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0833334Medicaid