Provider Demographics
NPI:1487114088
Name:GUAN, XIAOMU
Entity type:Individual
Prefix:
First Name:XIAOMU
Middle Name:
Last Name:GUAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4322 S CLEVELAND MASSILLON RD STE A
Mailing Address - Street 2:
Mailing Address - City:NORTON
Mailing Address - State:OH
Mailing Address - Zip Code:44203-5718
Mailing Address - Country:US
Mailing Address - Phone:330-825-7602
Mailing Address - Fax:
Practice Address - Street 1:4322 S CLEVELAND MASSILLON RD STE A
Practice Address - Street 2:
Practice Address - City:NORTON
Practice Address - State:OH
Practice Address - Zip Code:44203-5718
Practice Address - Country:US
Practice Address - Phone:330-825-7602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-21
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH30.0260561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program