Provider Demographics
NPI:1538380662
Name:WESTERN LAKE ERIE OMS LTD.
Entity type:Organization
Organization Name:WESTERN LAKE ERIE OMS LTD.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:SHALL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:419-479-3939
Mailing Address - Street 1:5690 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-2736
Mailing Address - Country:US
Mailing Address - Phone:419-479-3939
Mailing Address - Fax:419-479-3933
Practice Address - Street 1:5690 MONROE ST
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-2736
Practice Address - Country:US
Practice Address - Phone:419-479-3939
Practice Address - Fax:419-479-3933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1215932504OtherNPI NUMBER
OH1578568861OtherNPI NUMBER
OH1891795233OtherNPI NUMBER