Provider Demographics
NPI:1205233277
Name:TM WYLAND DENTAL LAB II
Entity type:Organization
Organization Name:TM WYLAND DENTAL LAB II
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:BIDDLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-824-2515
Mailing Address - Street 1:947 HALLOCK YOUNG RD SW
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44481-9636
Mailing Address - Country:US
Mailing Address - Phone:330-824-2515
Mailing Address - Fax:330-824-2333
Practice Address - Street 1:947 HALLOCK YOUNG RD SW
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44481-9636
Practice Address - Country:US
Practice Address - Phone:330-824-2515
Practice Address - Fax:330-824-2333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-19
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2037076Medicaid
OH0541677Medicaid