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3079 W. Broad Ste Suite 7 Columbus OH 43204 | |
| (614) 279-9204 | |
| (614) 279-9208 |
| Full Name | |
|---|---|
| Speciality | Dentist |
| Location | 3079 W. Broad Ste Suite 7, Columbus, Ohio |
| Authorized Official Name and Position | Jack Daniel Castilla (DENTIST) |
| Authorized Official Contact | 6142799204 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
3079 W. Broad Ste Suite 7 Columbus OH 43204 Ph: (614) 279-9204 | 3079 W. Broad Ste Suite 7 Columbus OH 43204 Ph: (614) 279-9204 |
| NPI Number | 1619086717 |
|---|---|
| Provider Enumeration Date | 08/30/2006 |
| Last Update Date | 10/03/2024 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1619086717 | NPI | - | NPPES |
| 2210039 | Medicaid | OH | |
| 9180566 | Other | OH | MOLINA HEALTH |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 122300000X | Dentist | 30016727 (Ohio) | Primary |
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