Provider Demographics
NPI:1144465907
Name:DAYTON DENTAL COLLABORATIVE
Entity type:Organization
Organization Name:DAYTON DENTAL COLLABORATIVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:R. GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHELHOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:937-435-5163
Mailing Address - Street 1:5685 FAR HILLS AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45429-2226
Mailing Address - Country:US
Mailing Address - Phone:937-435-5163
Mailing Address - Fax:937-291-9353
Practice Address - Street 1:5685 FAR HILLS AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45429-2226
Practice Address - Country:US
Practice Address - Phone:937-435-5163
Practice Address - Fax:937-291-9353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-09
Last Update Date:2008-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH157991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty