Provider Demographics
NPI:1245691492
Name:DAVID R. BACKUS DDS, INC.
Entity type:Organization
Organization Name:DAVID R. BACKUS DDS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:J
Authorized Official - Last Name:BACKUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-476-1484
Mailing Address - Street 1:4720 JACKMAN RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43612-2077
Mailing Address - Country:US
Mailing Address - Phone:419-476-1484
Mailing Address - Fax:419-476-6914
Practice Address - Street 1:4720 JACKMAN RD
Practice Address - Street 2:SUITE A
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43612-2077
Practice Address - Country:US
Practice Address - Phone:419-476-1484
Practice Address - Fax:419-476-6914
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-16
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH181871223D0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0004XDental ProvidersDentistDental AnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0934181Medicaid