Provider Demographics
NPI:1699047670
Name:DENTAL GROUP OF MENTOR
Entity type:Organization
Organization Name:DENTAL GROUP OF MENTOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:KLINEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-352-5700
Mailing Address - Street 1:9571 MENTOR AVE
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-4521
Mailing Address - Country:US
Mailing Address - Phone:440-352-5700
Mailing Address - Fax:440-352-5721
Practice Address - Street 1:9571 MENTOR AVE
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-4521
Practice Address - Country:US
Practice Address - Phone:440-352-5700
Practice Address - Fax:440-352-5721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-06
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30021252261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental