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1313 W Bogart Rd Sandusky OH 44870-5704 | |
| (419) 627-1255 | |
| (419) 627-0422 |
| Full Name | |
|---|---|
| Speciality | Clinic/center - Dental |
| Location | 1313 W Bogart Rd, Sandusky, Ohio |
| Authorized Official Name and Position | Diane L Ulichney (CREDENTIALING MANAGER) |
| Authorized Official Contact | 4403459068 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
6315 Pearl Rd Ste 201 Parma Heights OH 44130-3074 Ph: (440) 345-9068 | 1313 W Bogart Rd Sandusky OH 44870-5704 Ph: (419) 627-1255 |
| NPI Number | 1962687616 |
|---|---|
| Provider Enumeration Date | 12/31/2007 |
| Last Update Date | 05/13/2009 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1962687616 | NPI | - | NPPES |
| 2497454 | Medicaid | OH |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QD0000X | Clinic/center - Dental | 19758 (Ohio) | Primary |
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