Provider Demographics
NPI:1871608380
Name:DENTAL CLINIC COLLEGE OF DENTISTRY
Entity type:Organization
Organization Name:DENTAL CLINIC COLLEGE OF DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT DEAN
Authorized Official - Prefix:DR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:
Authorized Official - Last Name:FISCHBACH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:614-292-0050
Mailing Address - Street 1:305 W 12TH AVE
Mailing Address - Street 2:ROOM 1130 POSTLE HALL
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43210-1267
Mailing Address - Country:US
Mailing Address - Phone:614-292-6983
Mailing Address - Fax:614-688-3671
Practice Address - Street 1:305 W 12TH AVE
Practice Address - Street 2:ROOM 1130 POSTLE HALL
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210-1267
Practice Address - Country:US
Practice Address - Phone:614-292-6983
Practice Address - Fax:614-688-3671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2412535+0098193OtherBCMH GENERAL COLLEGE
OH316025986028OtherCARESOURCE
OH2414024+0098193OtherBCMH ORTHODONTICS COLLEGE
OH88300OtherDELTA DENTAL
OH0098193Medicaid
OH54350690400OtherBUREAU OF WORKMAN'S COMP