Provider Demographics
NPI:1649437336
Name:STREETSBORO DENTAL PARTNERS INC
Entity type:Organization
Organization Name:STREETSBORO DENTAL PARTNERS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LYDIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HARTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-626-3814
Mailing Address - Street 1:PO BOX 2006
Mailing Address - Street 2:1727 STREETSBORO PLAZA
Mailing Address - City:STREETSBORO
Mailing Address - State:OH
Mailing Address - Zip Code:44241-0006
Mailing Address - Country:US
Mailing Address - Phone:330-626-3814
Mailing Address - Fax:330-626-2169
Practice Address - Street 1:1727 STREETSBORO PLZ
Practice Address - Street 2:
Practice Address - City:STREETSBORO
Practice Address - State:OH
Practice Address - Zip Code:44241-5635
Practice Address - Country:US
Practice Address - Phone:330-626-3814
Practice Address - Fax:330-626-2169
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-20
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH206241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2029361Medicaid