Provider Demographics
NPI:1295115343
Name:PINNACLE ONE DENTAL GROUP
Entity type:Organization
Organization Name:PINNACLE ONE DENTAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-2100
Mailing Address - Street 1:5976 MEIJER DR STE 110B
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:OH
Mailing Address - Zip Code:45150-2191
Mailing Address - Country:US
Mailing Address - Phone:513-712-1085
Mailing Address - Fax:
Practice Address - Street 1:5976 MEIJER DR STE 110B
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:OH
Practice Address - Zip Code:45150-2191
Practice Address - Country:US
Practice Address - Phone:513-712-1085
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PINNACLE ONE DENTAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-06-04
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0244561223G0001X
1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty