Provider Demographics
NPI:1770898074
Name:DENTAL EXPRESS MEDINA -JERRY S. KOLOSIONEK DDS LLC
Entity type:Organization
Organization Name:DENTAL EXPRESS MEDINA -JERRY S. KOLOSIONEK DDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:R
Authorized Official - Last Name:MAUERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-533-3400
Mailing Address - Street 1:750 E WASHINGTON ST
Mailing Address - Street 2:SUITE A3
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-2196
Mailing Address - Country:US
Mailing Address - Phone:330-725-3887
Mailing Address - Fax:
Practice Address - Street 1:750 E WASHINGTON ST
Practice Address - Street 2:SUITE A3
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-2196
Practice Address - Country:US
Practice Address - Phone:330-725-3887
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-11
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-023197122300000X
OH30-023233122300000X
OH30-019480122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1143641-00-3Medicaid