Provider Demographics
NPI:1063061703
Name:OHIO DENTAL PROFESSIONALS, DELISLE, P.C.
Entity type:Organization
Organization Name:OHIO DENTAL PROFESSIONALS, DELISLE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:TABATHA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEMKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-6078
Mailing Address - Street 1:485 N AURORA RD
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:OH
Mailing Address - Zip Code:44202-8721
Mailing Address - Country:US
Mailing Address - Phone:330-562-1644
Mailing Address - Fax:
Practice Address - Street 1:485 N AURORA RD
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:OH
Practice Address - Zip Code:44202-8721
Practice Address - Country:US
Practice Address - Phone:330-562-1644
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OHIO DENTAL PROFESSIONALS, DELISLE, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-09-05
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty