Provider Demographics
NPI:1740035468
Name:ELLERHORST DENTAL, LLC
Entity type:Organization
Organization Name:ELLERHORST DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LYDIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLERHORST
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:330-221-4270
Mailing Address - Street 1:PO BOX 350
Mailing Address - Street 2:
Mailing Address - City:MANTUA
Mailing Address - State:OH
Mailing Address - Zip Code:44255-0350
Mailing Address - Country:US
Mailing Address - Phone:330-221-4270
Mailing Address - Fax:
Practice Address - Street 1:10730 MAIN ST APT 2
Practice Address - Street 2:
Practice Address - City:MANTUA
Practice Address - State:OH
Practice Address - Zip Code:44255-8951
Practice Address - Country:US
Practice Address - Phone:330-274-3495
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-17
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental