Provider Demographics
NPI:1952407686
Name:OLENTANGY PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:OLENTANGY PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:T
Authorized Official - Last Name:MILTON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:614-433-7474
Mailing Address - Street 1:45 CLAIREDAN DR
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:OH
Mailing Address - Zip Code:43065
Mailing Address - Country:US
Mailing Address - Phone:614-433-7474
Mailing Address - Fax:614-433-9090
Practice Address - Street 1:45 CLAIREDAN DR
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:OH
Practice Address - Zip Code:43065
Practice Address - Country:US
Practice Address - Phone:614-433-7474
Practice Address - Fax:614-433-9090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH218741223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2565808Medicaid
OH=========OtherMOLINA
OH2565808Medicaid