Healthcare Provider Details

I. General information

NPI: 1265642045
Provider Name (Legal Business Name): JUDITH LEE MANEELY RDH, EFDA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3456 MAYFIELD RD
CLEVELAND OH
44118-1405
US

IV. Provider business mailing address

1147 E 174TH ST
CLEVELAND OH
44119-3107
US

V. Phone/Fax

Practice location:
  • Phone: 440-442-3800
  • Fax: 440-442-3800
Mailing address:
  • Phone: 216-383-1737
  • Fax: 216-383-1737

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number3388
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number4404
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: