Provider Demographics
NPI:1538415203
Name:DOCTORS DOTY & GAEBELEIN
Entity type:Organization
Organization Name:DOCTORS DOTY & GAEBELEIN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MATT
Authorized Official - Middle Name:M
Authorized Official - Last Name:GAEBELEIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:330-225-0105
Mailing Address - Street 1:4313 REGAL AVE
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:OH
Mailing Address - Zip Code:44212-2978
Mailing Address - Country:US
Mailing Address - Phone:330-225-0105
Mailing Address - Fax:330-220-7883
Practice Address - Street 1:4313 REGAL AVE
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:OH
Practice Address - Zip Code:44212-2978
Practice Address - Country:US
Practice Address - Phone:330-225-0105
Practice Address - Fax:330-220-7883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-31
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH148311223G0001X
OH200661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty