Provider Demographics
NPI:1982142113
Name:RIVERFAMILYDENTALPRESENTEDBYDR.MANALSUNNADDSLLC
Entity Type:Organization
Organization Name:RIVERFAMILYDENTALPRESENTEDBYDR.MANALSUNNADDSLLC
Other - Org Name:RIVER FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CATHRYN
Authorized Official - Middle Name:
Authorized Official - Last Name:BUCKNER
Authorized Official - Suffix:
Authorized Official - Credentials:DENTAL ASSITANT
Authorized Official - Phone:216-268-3060
Mailing Address - Street 1:4163 PEARL RD
Mailing Address - Street 2:28651 TOUCHSTONE CIR
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44109-3332
Mailing Address - Country:US
Mailing Address - Phone:440-454-4878
Mailing Address - Fax:216-862-3585
Practice Address - Street 1:4163 PEARL RD
Practice Address - Street 2:28651 TOUCHSTONE CIR
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44109-3332
Practice Address - Country:US
Practice Address - Phone:440-454-4878
Practice Address - Fax:216-862-3585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-08
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0066021Medicaid