Provider Demographics
NPI:1669576138
Name:DESANTIS, NICHOLAS ROBERT (DMD)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:ROBERT
Last Name:DESANTIS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1240 CRESCENT HEIGHTS RD
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-6408
Mailing Address - Country:US
Mailing Address - Phone:740-387-5196
Mailing Address - Fax:
Practice Address - Street 1:1240 CRESCENT HEIGHTS RD
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-6408
Practice Address - Country:US
Practice Address - Phone:740-387-5196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-12
Last Update Date:2008-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-016967122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0466768Medicaid