Provider Demographics
NPI:1699964759
Name:WESTERN RESERVE PERIODONTICS, INC
Entity type:Organization
Organization Name:WESTERN RESERVE PERIODONTICS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY/TREASURER
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDRICK
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROSENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:216-464-8985
Mailing Address - Street 1:3609 PARK EAST DR
Mailing Address - Street 2:#411
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-4331
Mailing Address - Country:US
Mailing Address - Phone:216-464-7338
Mailing Address - Fax:
Practice Address - Street 1:3609 PARK EAST DR
Practice Address - Street 2:#411
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-4331
Practice Address - Country:US
Practice Address - Phone:216-464-7338
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-15
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9286801Medicare PIN