Provider Demographics
NPI:1386292530
Name:MARYSVILLE DENTAL GROUP
Entity type:Organization
Organization Name:MARYSVILLE DENTAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MAHER
Authorized Official - Middle Name:
Authorized Official - Last Name:SOUDAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-578-0014
Mailing Address - Street 1:17791 STATE ROUTE 31
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43040-9607
Mailing Address - Country:US
Mailing Address - Phone:937-578-0014
Mailing Address - Fax:937-644-0660
Practice Address - Street 1:17791 STATE ROUTE 31
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43040-9607
Practice Address - Country:US
Practice Address - Phone:937-578-0014
Practice Address - Fax:937-644-0660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-30
Last Update Date:2019-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty