Basic Information
Provider Information
NPI: 1063023430
EntityType: 2
ReplacementNPI:  
OrganizationName: WESTSIDE DENTAL SLEEP CENTER LLC
LastName:  
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Credential:  
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Mailing Information
Address1: 30701 LORAIN RD STE A
Address2:  
City: NORTH OLMSTED
State: OH
PostalCode: 440706325
CountryCode: US
TelephoneNumber: 4402745000
FaxNumber:  
Practice Location
Address1: 18611 DETROIT AVE
Address2:  
City: LAKEWOOD
State: OH
PostalCode: 441073205
CountryCode: US
TelephoneNumber: 2162212210
FaxNumber:  
Other Information
ProviderEnumerationDate: 08/11/2020
LastUpdateDate: 08/11/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: PAP
AuthorizedOfficialFirstName: MICHAEL
AuthorizedOfficialMiddleName: S
AuthorizedOfficialTitleorPosition: PRESIDENT
AuthorizedOfficialTelephone: 2162212210
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
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AuthorizedOfficialCredential: DDS
NPICertificationDate: 08/11/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1223P0700X  Y193400000X SINGLE SPECIALTY GROUPDental ProvidersDentistProsthodontics

ID Information
IDTypeStateIssuerDescription
450886201OHOHIO BUSINESS LICENSEOTHER


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