Provider Demographics
NPI:1487761987
Name:DETWILER, JAMES RUSSELL (DDS)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:RUSSELL
Last Name:DETWILER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:880 COMMERCE DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-5240
Mailing Address - Country:US
Mailing Address - Phone:419-874-3129
Mailing Address - Fax:419-874-5007
Practice Address - Street 1:880 COMMERCE DR
Practice Address - Street 2:SUITE A
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-5240
Practice Address - Country:US
Practice Address - Phone:419-874-3129
Practice Address - Fax:419-874-5007
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH138671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0217134Medicaid