Provider Demographics
NPI:1386391456
Name:OSU OBSERVATION MEDICINE SVS DENTAL
Entity type:Organization
Organization Name:OSU OBSERVATION MEDICINE SVS DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:K
Authorized Official - Last Name:MOELLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-293-5288
Mailing Address - Street 1:700 ACKERMAN RD STE 2120
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1559
Mailing Address - Country:US
Mailing Address - Phone:614-293-2046
Mailing Address - Fax:614-293-4078
Practice Address - Street 1:410 W 10TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210-1240
Practice Address - Country:US
Practice Address - Phone:614-293-8487
Practice Address - Fax:614-293-8153
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OSU OBSERVATION MEDICINE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-03-08
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0004XDental ProvidersDentistDental AnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0486983Medicaid