Basic Information
| Provider Information | |||||||||
| NPI: | 1215336912 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DAYTON CHILDRENS DENTAL CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 324 22ND AVE N | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372031842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153216176 | ||||||||
| FaxNumber: | 6153213175 | ||||||||
| Practice Location | |||||||||
| Address1: | 4257 W 3RD ST | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454171406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372681665 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2014 | ||||||||
| LastUpdateDate: | 01/22/2015 | ||||||||
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| AuthorizedOfficialLastName: | GRAMMER | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | DISTRICT MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6158813808 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DS4614 | TN | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist |
No ID Information.