Basic Information
| Provider Information | |||||||||
| NPI: | 1912988163 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOLLICA | ||||||||
| FirstName: | THANH | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | D.D.S., PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1320 MERCY DR NW | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447082614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304891000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1320 MERCY DR NW | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447082614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304891000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2005 | ||||||||
| LastUpdateDate: | 12/02/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 50-002308 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 122300000X | RES3745 | OH | N | Dental Providers | Dentist | 122300000X | 30.024762 | OH | Y | Dental Providers | Dentist |
No ID Information.