Provider Demographics
NPI:1356407258
Name:MID OHIO ORAL SURGERY, INC.
Entity type:Organization
Organization Name:MID OHIO ORAL SURGERY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT - SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:T
Authorized Official - Last Name:LATHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:6141-878-7778
Mailing Address - Street 1:4488 W BROAD ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43228-5610
Mailing Address - Country:US
Mailing Address - Phone:614-878-7778
Mailing Address - Fax:614-878-2725
Practice Address - Street 1:4488 W BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43228-5610
Practice Address - Country:US
Practice Address - Phone:614-878-7778
Practice Address - Fax:614-878-2725
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0417758Medicaid
OH0417758Medicaid
OHMI9931841Medicare ID - Type Unspecified