Provider Demographics
NPI:1528282548
Name:CHILDREN'S CLINIC OF COSHOCTON COUNTY, INC
Entity type:Organization
Organization Name:CHILDREN'S CLINIC OF COSHOCTON COUNTY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DUNLAP
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:740-622-8421
Mailing Address - Street 1:406 S 15TH ST
Mailing Address - Street 2:
Mailing Address - City:COSHOCTON
Mailing Address - State:OH
Mailing Address - Zip Code:43812-2285
Mailing Address - Country:US
Mailing Address - Phone:740-622-8421
Mailing Address - Fax:
Practice Address - Street 1:406 S 15TH ST
Practice Address - Street 2:
Practice Address - City:COSHOCTON
Practice Address - State:OH
Practice Address - Zip Code:43812-2285
Practice Address - Country:US
Practice Address - Phone:740-622-8421
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0191431223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0624891Medicaid