Provider Demographics
NPI:1548369564
Name:MARK A IACOBELLI D D S INC
Entity type:Organization
Organization Name:MARK A IACOBELLI D D S INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:IACOBELLI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS FAGD
Authorized Official - Phone:440-845-7300
Mailing Address - Street 1:8030 CORPORATE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:NORTH ROYALTON
Mailing Address - State:OH
Mailing Address - Zip Code:44133-1245
Mailing Address - Country:US
Mailing Address - Phone:440-845-7300
Mailing Address - Fax:440-845-7785
Practice Address - Street 1:8030 CORPORATE CIRCLE
Practice Address - Street 2:
Practice Address - City:NORTH ROYALTON
Practice Address - State:OH
Practice Address - Zip Code:44133-1245
Practice Address - Country:US
Practice Address - Phone:440-845-7300
Practice Address - Fax:440-845-7785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH170961223G0001X
122400000X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No122400000XDental ProvidersDenturistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OPT OUTMedicare ID - Type Unspecified