Basic Information
| Provider Information | |||||||||
| NPI: | 1912121112 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OCEAN DENTAL OF OHIO, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 206 W. SIXTH AVE | ||||||||
| Address2: | |||||||||
| City: | STILLWATER | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740744017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057070600 | ||||||||
| FaxNumber: | 4057070602 | ||||||||
| Practice Location | |||||||||
| Address1: | 3646 E. MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | WHITEHALL | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432132913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142314800 | ||||||||
| FaxNumber: | 6142314801 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HOECKER | ||||||||
| AuthorizedOfficialFirstName: | CHAD | ||||||||
| AuthorizedOfficialMiddleName: | B. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4057070600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 2680899 | 05 | OH | MEDICAID | 112063 | 01 | OH | DORAL PROVIDER NUMBER | OTHER |