Provider Demographics
NPI:1548663040
Name:LARGE, JANICE
Entity type:Individual
Prefix:
First Name:JANICE
Middle Name:
Last Name:LARGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 PRICE RD
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-9506
Mailing Address - Country:US
Mailing Address - Phone:740-349-6535
Mailing Address - Fax:740-349-6510
Practice Address - Street 1:675 PRICE RD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-9506
Practice Address - Country:US
Practice Address - Phone:740-349-6535
Practice Address - Fax:740-349-6510
Is Sole Proprietor?:No
Enumeration Date:2014-09-29
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH31-003084124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH31-6400074Medicaid