Basic Information
| Provider Information | |||||||||
| NPI: | 1649241787 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY SURGICAL-DENTAL ASSOCIATES, LLC | ||||||||
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| OtherOrganizationName: | UNIVERSITY SURGICAL DENTAL ASSOCIATES, INC. | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3200 BURNET AVE | ||||||||
| Address2: | 3 SOUTH, CREDENTIALING | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452293019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135855502 | ||||||||
| FaxNumber: | 5135855511 | ||||||||
| Practice Location | |||||||||
| Address1: | 222 PIEDMONT AVE. | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452194231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5134758783 | ||||||||
| FaxNumber: | 5134757698 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2006 | ||||||||
| LastUpdateDate: | 09/16/2019 | ||||||||
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| AuthorizedOfficialLastName: | HINDS | ||||||||
| AuthorizedOfficialFirstName: | HUGH | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE VP/CFO | ||||||||
| AuthorizedOfficialTelephone: | 5135858720 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | 1223S0112X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Oral and Maxillofacial Surgery | 204E00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Oral & Maxillofacial Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0404048 | 05 | OH | MEDICAID |