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633 N Union St Loudonville OH 44842-1074 | |
(419) 994-3111 | |
(419) 994-4078 |
Full Name | |
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Speciality | Clinic/Center |
Location | 633 N Union St, Loudonville, Ohio |
Authorized Official Name and Position | Darrel L Scott (OWNER) |
Authorized Official Contact | 4199943111 |
Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
Mailing Address | Practice Location Address |
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633 N Union St Loudonville OH 44842-1074 Ph: (419) 994-3111 | 633 N Union St Loudonville OH 44842-1074 Ph: (419) 994-3111 |
NPI Number | 1073828786 |
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Provider Enumeration Date | 08/18/2010 |
Last Update Date | 08/18/2010 |
Medicare PECOS PAC ID | 3173930617 |
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Medicare Enrollment ID | O20210329001077 |
Identifier | Type | State | Issuer |
---|---|---|---|
1073828786 | NPI | - | NPPES |
2969097 | Medicaid | OH | |
0436611 | Medicaid | OH |
Taxonomy | Type | License (State) | Status |
---|---|---|---|
261QD0000X | Clinic/center - Dental | 16373 (Ohio) | Primary |
Provider Name | Tyler Lynn Scott |
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Provider Type | Practitioner - Dentist |
Provider Identifiers | NPI Number: 1174752992 PECOS PAC ID: 4082021522 Enrollment ID: I20210420001456 |