Provider Demographics
NPI:1053597930
Name:A REZA MIREMADI MD DDS LLC
Entity type:Organization
Organization Name:A REZA MIREMADI MD DDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:
Authorized Official - Last Name:LAYMASTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-748-8814
Mailing Address - Street 1:576 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45066-9552
Mailing Address - Country:US
Mailing Address - Phone:937-748-8814
Mailing Address - Fax:937-748-8817
Practice Address - Street 1:576 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGBORO
Practice Address - State:OH
Practice Address - Zip Code:45066-9552
Practice Address - Country:US
Practice Address - Phone:937-748-8814
Practice Address - Fax:937-748-8817
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-10
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2421132Medicaid
OH9337901Medicare PIN
OHH94832Medicare UPIN