MEDICARE: MISS JUDITH LEE MANEELY RDH, EFDA

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	124Q00000X	Dental Hygienist	3388	OH
2	124Q00000X	Dental Hygienist	4404	TX

General Provider Information

NPI Number	:	1265642045
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS JUDITH LEE MANEELY RDH, EFDA

Provider Business Mailing Address
First Line	:	1147 E 174TH ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44119-3107
Country	:	US
Telephone Number	:	216-383-1737
Fax Number	:	216-383-1737

Provider Business Practice Location Address
First Line	:	3456 MAYFIELD RD
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44118-1405
Country	:	US
Telephone Number	:	440-442-3800
Fax Number	:	440-442-3800

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

Provider Enumeration Date	:	05/23/2007
Last Update Date	:	07/08/2007

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