Provider Demographics
NPI:1255546503
Name:SACKRIDER, TANYA KILEY (DDS)
Entity type:Individual
Prefix:DR
First Name:TANYA
Middle Name:KILEY
Last Name:SACKRIDER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 WARDS CORNER RD STE 200
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:45140-6966
Mailing Address - Country:US
Mailing Address - Phone:513-707-4041
Mailing Address - Fax:
Practice Address - Street 1:1341 CLOUGH PIKE STE 150
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:OH
Practice Address - Zip Code:45103
Practice Address - Country:US
Practice Address - Phone:513-732-5088
Practice Address - Fax:513-231-2620
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ70341223G0001X
OH30.0252531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0334460Medicaid