Provider Demographics
NPI:1255049110
Name:OHIO DENTAL PROFESSIONALS, DELISLE, P.C.
Entity type:Organization
Organization Name:OHIO DENTAL PROFESSIONALS, DELISLE, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTEITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8306
Mailing Address - Street 1:13616 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-4709
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13616 MADISON AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-4709
Practice Address - Country:US
Practice Address - Phone:216-221-1438
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OHIO DENTAL PROFESSIONALS, DELISLE, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-11-09
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty