Basic Information
| Provider Information | |||||||||
| NPI: | 1255546503 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SACKRIDER | ||||||||
| FirstName: | TANYA | ||||||||
| MiddleName: | KILEY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 424 WARDS CORNER RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | LOVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 451406966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137074041 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1341 CLOUGH PIKE STE 150 | ||||||||
| Address2: | |||||||||
| City: | BATAVIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137325088 | ||||||||
| FaxNumber: | 5132312620 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2007 | ||||||||
| LastUpdateDate: | 09/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 09/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 7034 | AZ | N | Dental Providers | Dentist | General Practice | 1223G0001X | 30.025253 | OH | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 0334460 | 05 | OH | MEDICAID |