Provider Demographics
NPI:1780079038
Name:BEREA FAMILY DENTAL
Entity type:Organization
Organization Name:BEREA FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-206-4080
Mailing Address - Street 1:359 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:OH
Mailing Address - Zip Code:44017-1760
Mailing Address - Country:US
Mailing Address - Phone:440-234-2813
Mailing Address - Fax:
Practice Address - Street 1:20 S LIMESTONE ST
Practice Address - Street 2:SUITE110
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45502-2219
Practice Address - Country:US
Practice Address - Phone:937-322-7832
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-03
Last Update Date:2015-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH15902122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2809232Medicaid
OH0431321Medicaid