Provider Demographics
NPI:1316576556
Name:VAUGHAN, PETR ALEXANDER
Entity type:Individual
Prefix:
First Name:PETR
Middle Name:ALEXANDER
Last Name:VAUGHAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5310 WAKEFIELD PL
Mailing Address - Street 2:
Mailing Address - City:NORWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45212-1737
Mailing Address - Country:US
Mailing Address - Phone:937-245-0390
Mailing Address - Fax:
Practice Address - Street 1:6558 GLENWAY AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45211-4410
Practice Address - Country:US
Practice Address - Phone:513-613-3232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-08
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH300261301223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program