Provider Demographics
NPI:1326019233
Name:UNIVERSITY SUBURBAN DENTAL GROUP, INC
Entity type:Organization
Organization Name:UNIVERSITY SUBURBAN DENTAL GROUP, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-381-6521
Mailing Address - Street 1:1611 S GREEN RD
Mailing Address - Street 2:SUITE 157
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44121-4128
Mailing Address - Country:US
Mailing Address - Phone:216-381-6521
Mailing Address - Fax:216-381-9226
Practice Address - Street 1:1611 S GREEN RD
Practice Address - Street 2:SUITE 157
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44121-4128
Practice Address - Country:US
Practice Address - Phone:216-381-6521
Practice Address - Fax:216-381-9226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-30
Last Update Date:2009-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-01-74181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty