Gilbert Russell Backus Jr., DDS
Individual provider Active NPI Dentist · Boardman, OH
NPI 1063572162 · NPPES record last updated Jul 8, 2007
Key facts
- NPI
- 1063572162
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Dentist 122300000X
- License
- 30013429 (OH)
- Practice address
- 810 Boardman Canfield Rd
Boardman, OH 44512-4200 - Phone
- (330) 758-7931
- NPI assigned
- Dec 11, 2006
- Sex
- Male
- Sole proprietor
- No
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 30013429 | OH | MD | Dentist |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 30013429 | OH | Yes |
Addresses
Primary practice location
810 Boardman Canfield Rd
Boardman, OH 44512-4200
Mailing address
810 Boardman Canfield Rd
Boardman, OH 44512-4200
Phone (330) 758-7931
Other providers in Boardman, OH
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 8, 2007. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.