Provider Demographics
NPI:1780078287
Name:OHIO DENTAL PROFESSIONALS, DELISLE, PC
Entity type:Organization
Organization Name:OHIO DENTAL PROFESSIONALS, DELISLE, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:INSURANCE/CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLSWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5100
Mailing Address - Street 1:6160 GENDER RD
Mailing Address - Street 2:
Mailing Address - City:CANAL WINCHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:43110-2054
Mailing Address - Country:US
Mailing Address - Phone:614-930-6940
Mailing Address - Fax:
Practice Address - Street 1:6160 GENDER RD
Practice Address - Street 2:
Practice Address - City:CANAL WINCHESTER
Practice Address - State:OH
Practice Address - Zip Code:43110-2054
Practice Address - Country:US
Practice Address - Phone:614-930-6940
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OHIO DENTAL PROFESSIONALS, DELISLE, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-03-23
Last Update Date:2015-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty