Basic Information
| Provider Information | |||||||||
| NPI: | 1386605152 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HIRSCH | ||||||||
| FirstName: | STANLEY | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30701 LORAIN RD | ||||||||
| Address2: | STE A | ||||||||
| City: | NORTH OLMSTED | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440706325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402745000 | ||||||||
| FaxNumber: | 4407168608 | ||||||||
| Practice Location | |||||||||
| Address1: | 6365 LONGRIDGE RD | ||||||||
| Address2: | |||||||||
| City: | MAYFIELD HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441244114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4406462552 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2006 | ||||||||
| LastUpdateDate: | 08/24/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223P0106X | 30-014094 | OH | Y | Dental Providers | Dentist | Oral and Maxillofacial Pathology |
ID Information
| ID | Type | State | Issuer | Description | 000000115378 | 01 | OH | ANTHEM | OTHER | 11649450001 | 05 | WY | MEDICAID | 1100582 | 01 | OH | UNITED HEALTHCARE | OTHER |