Basic Information
| Provider Information | |||||||||
| NPI: | 1851631246 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PINNACLE ONE DENTAL GROUP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | CINCINNATI DENTAL SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 5976 MEIJER DR STE 110B | ||||||||
| Address2: | |||||||||
| City: | MILFORD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 451502191 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137212444 | ||||||||
| FaxNumber: | 5137212398 | ||||||||
| Practice Location | |||||||||
| Address1: | 5976 MEIJER DR STE 110B | ||||||||
| Address2: | |||||||||
| City: | MILFORD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 451502191 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137212444 | ||||||||
| FaxNumber: | 5137212398 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2013 | ||||||||
| LastUpdateDate: | 02/21/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FAUST | ||||||||
| AuthorizedOfficialFirstName: | LARRY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5137212444 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CINCINNATI DENTAL SERVICES | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | 14417 | OH | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
No ID Information.