Provider Demographics
NPI:1386088185
Name:E. V. DECASTECKER DDS INC
Entity type:Organization
Organization Name:E. V. DECASTECKER DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ESTELA
Authorized Official - Middle Name:V
Authorized Official - Last Name:DECASTECKER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:440-975-9885
Mailing Address - Street 1:7320 INDUSTRIAL PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-5318
Mailing Address - Country:US
Mailing Address - Phone:440-975-9885
Mailing Address - Fax:440-975-1634
Practice Address - Street 1:7320 INDUSTRIAL PARK BLVD
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-5318
Practice Address - Country:US
Practice Address - Phone:440-975-9885
Practice Address - Fax:440-975-1634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-23
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300206521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH30020652OtherLICENCE
OH3087887Medicaid