Provider Demographics
NPI:1700927498
Name:WILLIAM D SQUIRES DDS MS INC
Entity Type:Organization
Organization Name:WILLIAM D SQUIRES DDS MS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:DECKER
Authorized Official - Last Name:SQUIRES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS & MS ORTHODONTIC
Authorized Official - Phone:440-331-0055
Mailing Address - Street 1:20800 WESTGATE MEDICAL CENTER
Mailing Address - Street 2:SUITE 108
Mailing Address - City:FAIRVIEW PARK
Mailing Address - State:OH
Mailing Address - Zip Code:44126
Mailing Address - Country:US
Mailing Address - Phone:440-331-0055
Mailing Address - Fax:440-331-0056
Practice Address - Street 1:20800 WESTGATE MEDICAL CENTER
Practice Address - Street 2:SUITE 108
Practice Address - City:FAIRVIEW PARK
Practice Address - State:OH
Practice Address - Zip Code:44126
Practice Address - Country:US
Practice Address - Phone:440-331-0055
Practice Address - Fax:440-331-0056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH129811223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH=========027OtherCARE SOURCE