Basic Information
| Provider Information | |||||||||
| NPI: | 1982118709 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CLEVELAND DENTAL INSTITUTE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4071 LEE RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441282100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2167270234 | ||||||||
| FaxNumber: | 2167271164 | ||||||||
| Practice Location | |||||||||
| Address1: | 4071 LEE RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441282100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2167270234 | ||||||||
| FaxNumber: | 2167271164 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2017 | ||||||||
| LastUpdateDate: | 06/16/2018 | ||||||||
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| AuthorizedOfficialLastName: | ELRAWY | ||||||||
| AuthorizedOfficialFirstName: | HUSSEIN | ||||||||
| AuthorizedOfficialMiddleName: | F. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2167270234 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CLEVELAND DENTAL INSTITUTE | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | N | Ambulatory Health Care Facilities | Clinic/Center | 122300000X | 30023525 | OH | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist | 261QM1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 1223E0200X | 30024296 | OH | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist | Endodontics | 1223P0221X | 30024868 | OH | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist | Pediatric Dentistry | 122300000X | 30022649 | OH | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 230930922 | 05 | OH | MEDICAID |