Provider Demographics
NPI:1487733960
Name:MAIN STREET DENTAL INC
Entity type:Organization
Organization Name:MAIN STREET DENTAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:NULL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:740-344-4000
Mailing Address - Street 1:1822 SUTTON PLACE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055
Mailing Address - Country:US
Mailing Address - Phone:740-344-4410
Mailing Address - Fax:
Practice Address - Street 1:1339 W MAIN ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055
Practice Address - Country:US
Practice Address - Phone:740-344-4000
Practice Address - Fax:740-344-3139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH15386122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty