Provider Demographics
NPI:1699335570
Name:DENTAL STUDIO OF AVON LAKE LLC
Entity type:Organization
Organization Name:DENTAL STUDIO OF AVON LAKE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:JUNGERMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-899-7950
Mailing Address - Street 1:32713 WALKER RD
Mailing Address - Street 2:
Mailing Address - City:AVON LAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44012-2232
Mailing Address - Country:US
Mailing Address - Phone:440-933-7950
Mailing Address - Fax:
Practice Address - Street 1:32713 WALKER RD
Practice Address - Street 2:
Practice Address - City:AVON LAKE
Practice Address - State:OH
Practice Address - Zip Code:44012-2232
Practice Address - Country:US
Practice Address - Phone:440-933-7950
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-13
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
1326136896OtherNPI
1497180889OtherNPI