MEDICARE: DENTAL PROFESSIONALS CLEVELAND-LEE,INC.

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

General Provider Information

NPI Number	:	1184896433
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL PROFESSIONALS CLEVELAND-LEE,INC.

Provider Business Mailing Address
First Line	:	435 GRISWOLD RD
Second Line	:
City	:	ELYRIA
State	:	OH
Zip	:	44035-2304
Country	:	US
Telephone Number	:	440-324-2310
Fax Number	:	440-324-9467

Provider Business Practice Location Address
First Line	:	435 GRISWOLD RD
Second Line	:
City	:	ELYRIA
State	:	OH
Zip	:	44035-2304
Country	:	US
Telephone Number	:	440-324-2310
Fax Number	:	440-324-9467

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	DIANE ULICHNEY
Credential	:
Telephone Number	:	440-324-2310

Provider Enumeration Date	:	03/27/2008
Last Update Date	:	03/27/2008

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