MEDICARE: DR. MICHAEL E O'LEARY I D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	21032	OH

General Provider Information

NPI Number	:	1215033568
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL E O'LEARY I D.D.S.

Provider Business Mailing Address
First Line	:	13425 DETROIT AVE
Second Line	:
City	:	LAKEWOOD
State	:	OH
Zip	:	44107-4608
Country	:	US
Telephone Number	:	440-333-1177
Fax Number	:	216-529-2218

Provider Business Practice Location Address
First Line	:	13425 DETROIT AVE
Second Line	:
City	:	LAKEWOOD
State	:	OH
Zip	:	44107-4608
Country	:	US
Telephone Number	:	440-333-1177
Fax Number	:	216-529-2218

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/15/2006
Last Update Date	:	07/08/2007

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