Basic Information
Provider Information | |||||||||
NPI: | 1710575360 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BOUNDLESS HEALTH, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BOUNDLESS HEALTH, INC. | ||||||||
OtherOrganizationType: | 4 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 445 E DUBLIN GRANVILLE RD | ||||||||
Address2: |   | ||||||||
City: | WORTHINGTON | ||||||||
State: | OH | ||||||||
PostalCode: | 43085 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6148443800 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 445 E DUBLIN GRANVILLE RD | ||||||||
Address2: |   | ||||||||
City: | WORTHINGTON | ||||||||
State: | OH | ||||||||
PostalCode: | 43085 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6148443800 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/08/2021 | ||||||||
LastUpdateDate: | 05/19/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | YOUNG | ||||||||
AuthorizedOfficialFirstName: | DERRICK | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CONTRACTING & CREDENTIALING MANAGER | ||||||||
AuthorizedOfficialTelephone: | 6148443800 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/19/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice | 1223P0221X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Pediatric Dentistry | 122300000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist |   |
No ID Information.