Healthcare Provider Details

I. General information

NPI: 1851462402
Provider Name (Legal Business Name): THOMAS DIMASSA D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15700 MADISON AVE
LAKEWOOD OH
44107-5613
US

IV. Provider business mailing address

15700 MADISON AVE
LAKEWOOD OH
44107-5613
US

V. Phone/Fax

Practice location:
  • Phone: 216-521-9944
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number30-01-7032
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: