Provider Demographics
NPI:1962730549
Name:DENTAL EXPRESS BOARDMAN, TED A SCHUSTER DDS LLC
Entity type:Organization
Organization Name:DENTAL EXPRESS BOARDMAN, TED A SCHUSTER DDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:R
Authorized Official - Last Name:MAUERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-533-3400
Mailing Address - Street 1:6540 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-3651
Mailing Address - Country:US
Mailing Address - Phone:330-533-3400
Mailing Address - Fax:
Practice Address - Street 1:6540 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-3651
Practice Address - Country:US
Practice Address - Phone:330-533-3400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-19
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30022311122300000X
OH30015046122300000X
OH30020654122300000X
OH30-012873122300000X
OH30-01955122300000X
OH30-022882122300000X
OH30-023087122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2966992Medicaid
OH0296166Medicaid
OH2994578Medicaid