Provider Demographics
NPI:1215336912
Name:DAYTON CHILDRENS DENTAL CENTER, LLC
Entity type:Organization
Organization Name:DAYTON CHILDRENS DENTAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DISTRICT MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:GRAMMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-881-3808
Mailing Address - Street 1:324 22ND AVE N
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-1842
Mailing Address - Country:US
Mailing Address - Phone:615-321-6176
Mailing Address - Fax:615-321-3175
Practice Address - Street 1:4257 W 3RD ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-1406
Practice Address - Country:US
Practice Address - Phone:937-268-1665
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-19
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS4614122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
A98713Medicare UPIN