Provider Demographics
NPI:1194936724
Name:EDGEWOOD DENTAL CLINIC
Entity type:Organization
Organization Name:EDGEWOOD DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:R
Authorized Official - Last Name:THENOT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-868-9277
Mailing Address - Street 1:1 SOUTH EDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:OH
Mailing Address - Zip Code:45013-2505
Mailing Address - Country:US
Mailing Address - Phone:513-868-9277
Mailing Address - Fax:513-868-9277
Practice Address - Street 1:1 SOUTH EDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:OH
Practice Address - Zip Code:45013-2505
Practice Address - Country:US
Practice Address - Phone:513-868-9277
Practice Address - Fax:513-868-9277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300119941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
30011994OtherLICENSE NUMBER
30011994OtherLICENSE NUMBER