Provider Demographics
NPI:1831577717
Name:ALEXANDER J MCILVAINE DMD LLC
Entity type:Organization
Organization Name:ALEXANDER J MCILVAINE DMD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:JENTES
Authorized Official - Last Name:MCILVAINE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:330-414-4083
Mailing Address - Street 1:235 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:WADSWORTH
Mailing Address - State:OH
Mailing Address - Zip Code:44281-2112
Mailing Address - Country:US
Mailing Address - Phone:330-335-1563
Mailing Address - Fax:330-335-1563
Practice Address - Street 1:235 BROAD ST
Practice Address - Street 2:
Practice Address - City:WADSWORTH
Practice Address - State:OH
Practice Address - Zip Code:44281-2112
Practice Address - Country:US
Practice Address - Phone:330-335-1563
Practice Address - Fax:330-335-1563
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-12
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-0237081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty