Provider Demographics
NPI:1285909184
Name:G SCOTT LOUDERBACK DDS LLC
Entity type:Organization
Organization Name:G SCOTT LOUDERBACK DDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:S
Authorized Official - Last Name:LOUDERBACK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:419-693-1234
Mailing Address - Street 1:631 S WHEELING ST
Mailing Address - Street 2:
Mailing Address - City:OREGON
Mailing Address - State:OH
Mailing Address - Zip Code:43616-2742
Mailing Address - Country:US
Mailing Address - Phone:419-693-1234
Mailing Address - Fax:
Practice Address - Street 1:631 S WHEELING ST
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:OH
Practice Address - Zip Code:43616-2742
Practice Address - Country:US
Practice Address - Phone:419-693-1234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-12
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1316100167OtherINDIVIDUAL NPI NUMBER