Provider Demographics
NPI:1871011577
Name:MARDIS FAMILY DENTAL, LLC
Entity type:Organization
Organization Name:MARDIS FAMILY DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MARDIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-836-7991
Mailing Address - Street 1:55 S MILLER RD STE 104
Mailing Address - Street 2:
Mailing Address - City:FAIRLAWN
Mailing Address - State:OH
Mailing Address - Zip Code:44333-4167
Mailing Address - Country:US
Mailing Address - Phone:330-836-7991
Mailing Address - Fax:330-836-8064
Practice Address - Street 1:55 S MILLER RD STE 104
Practice Address - Street 2:
Practice Address - City:FAIRLAWN
Practice Address - State:OH
Practice Address - Zip Code:44333-4167
Practice Address - Country:US
Practice Address - Phone:330-836-7991
Practice Address - Fax:330-836-8064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.023452122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1235424227OtherNPI