Provider Demographics
NPI:1487770855
Name:DECHELLIS, ALBERT P (DDS)
Entity type:Individual
Prefix:DR
First Name:ALBERT
Middle Name:P
Last Name:DECHELLIS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 MARWOOD CIRCLE
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:330-726-4949
Practice Address - Street 1:60 MARWOOD CIRCLE
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512
Practice Address - Country:US
Practice Address - Phone:330-758-4800
Practice Address - Fax:330-726-4948
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH165511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0470039Medicaid