Provider Demographics
NPI:1982118709
Name:CLEVELAND DENTAL INSTITUTE LLC
Entity Type:Organization
Organization Name:CLEVELAND DENTAL INSTITUTE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HUSSEIN
Authorized Official - Middle Name:F
Authorized Official - Last Name:ELRAWY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:216-727-0234
Mailing Address - Street 1:4071 LEE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44128-2100
Mailing Address - Country:US
Mailing Address - Phone:216-727-0234
Mailing Address - Fax:216-727-1164
Practice Address - Street 1:4071 LEE RD STE 200
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44128-2100
Practice Address - Country:US
Practice Address - Phone:216-727-0234
Practice Address - Fax:216-727-1164
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLEVELAND DENTAL INSTITUTE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-12-01
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30022649122300000X
OH30023525122300000X
OH300242961223E0200X
OH300248681223P0221X
261Q00000X, 261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH230930922Medicaid