Provider Demographics
NPI:1194596981
Name:DYNAMIC DENTAL SPECIALISTS LLC
Entity type:Organization
Organization Name:DYNAMIC DENTAL SPECIALISTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:NORMAN
Authorized Official - Last Name:BEALE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:419-610-1620
Mailing Address - Street 1:583 WILES RD
Mailing Address - Street 2:
Mailing Address - City:MANFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44903
Mailing Address - Country:US
Mailing Address - Phone:419-610-1620
Mailing Address - Fax:419-756-4886
Practice Address - Street 1:583 WILES RD
Practice Address - Street 2:
Practice Address - City:MANFIELD
Practice Address - State:OH
Practice Address - Zip Code:44903
Practice Address - Country:US
Practice Address - Phone:419-610-1620
Practice Address - Fax:419-756-4886
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-11
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0250095Medicaid