Provider Demographics
NPI:1811170160
Name:FAMILY DENTAL CARE AT EAGLETON CENTER
Entity type:Organization
Organization Name:FAMILY DENTAL CARE AT EAGLETON CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALI
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAKSAFARD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:740-852-7741
Mailing Address - Street 1:391 LAFAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:OH
Mailing Address - Zip Code:43140-9326
Mailing Address - Country:US
Mailing Address - Phone:740-852-7741
Mailing Address - Fax:740-852-7783
Practice Address - Street 1:391 LAFAYETTE ST.
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:OH
Practice Address - Zip Code:43140-9195
Practice Address - Country:US
Practice Address - Phone:740-852-7741
Practice Address - Fax:740-852-7783
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-10
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental