Provider Demographics
NPI:1538772405
Name:BEACHCLIFF DENTAL ASSOCIATES OF ROCKY RIVER - A THEODOROU DMD LLC
Entity type:Organization
Organization Name:BEACHCLIFF DENTAL ASSOCIATES OF ROCKY RIVER - A THEODOROU DMD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHASE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-356-2089
Mailing Address - Street 1:19111 DETROIT RD STE 206
Mailing Address - Street 2:
Mailing Address - City:ROCKY RIVER
Mailing Address - State:OH
Mailing Address - Zip Code:44116-1740
Mailing Address - Country:US
Mailing Address - Phone:440-356-1000
Mailing Address - Fax:440-356-2090
Practice Address - Street 1:19111 DETROIT RD STE 204
Practice Address - Street 2:
Practice Address - City:ROCKY RIVER
Practice Address - State:OH
Practice Address - Zip Code:44116-1740
Practice Address - Country:US
Practice Address - Phone:440-356-1000
Practice Address - Fax:440-356-2090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-28
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0402338Medicaid