Provider Demographics
NPI:1568636660
Name:JOHN HERBERT GERSTENMAIER
Entity type:Organization
Organization Name:JOHN HERBERT GERSTENMAIER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:HERBERT
Authorized Official - Last Name:GERSTENMAIER
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:330-867-5688
Mailing Address - Street 1:3094 WEST MARKET ST
Mailing Address - Street 2:#260
Mailing Address - City:FAIRLAWN
Mailing Address - State:OH
Mailing Address - Zip Code:44333-3626
Mailing Address - Country:US
Mailing Address - Phone:330-867-5688
Mailing Address - Fax:330-867-9921
Practice Address - Street 1:3094 WEST MARKET ST
Practice Address - Street 2:#260
Practice Address - City:FAIRLAWN
Practice Address - State:OH
Practice Address - Zip Code:44333-3626
Practice Address - Country:US
Practice Address - Phone:330-867-5688
Practice Address - Fax:330-867-9921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-18
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300145371223P0221X
MI29010100571223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0273814Medicaid