Provider Demographics
NPI:1124090097
Name:COSMETIC & FAMILY DENTAL STUDIOS, LLC
Entity type:Organization
Organization Name:COSMETIC & FAMILY DENTAL STUDIOS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ABRAHAM
Authorized Official - Middle Name:H
Authorized Official - Last Name:BOADI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:419-534-2479
Mailing Address - Street 1:36 S BYRNE RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43615-6211
Mailing Address - Country:US
Mailing Address - Phone:419-534-2479
Mailing Address - Fax:419-534-3260
Practice Address - Street 1:36 S BYRNE RD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43615-6211
Practice Address - Country:US
Practice Address - Phone:419-534-2479
Practice Address - Fax:419-534-3260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH188421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0719486Medicaid
OH01541OtherPARAMOUNT ADVANTAGE
OH18842-436156211OtherDELTA DENTAL OH/MI