1316535479 NPI number — OLLOM DDS DELAWARE LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316535479 NPI number — OLLOM DDS DELAWARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OLLOM DDS DELAWARE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PURE SMILES DELAWARE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316535479
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/20/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2115 ALLENTOWN RD STE C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LIMA
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45805-1749
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-228-4036
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
833 W WILLIAM ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DELAWARE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43015-3754
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-362-1591
Provider Business Practice Location Address Fax Number:
740-363-0061
Provider Enumeration Date:
01/05/2021

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CAMPBELL
Authorized Official First Name:
JANE
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
DIRECTOR OF OPERATIONS
Authorized Official Telephone Number:
567-940-8141

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)