MEDICARE: DR. GREGORY F. DIEDERICH 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	1223G0001X	General Practice Dentistry	018711	OH

General Provider Information

NPI Number	:	1306066105
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GREGORY F. DIEDERICH D.D.S

Provider Business Mailing Address
First Line	:	5064 WATERFORD DR
Second Line	:
City	:	SHEFFIELD VILLAGE
State	:	OH
Zip	:	44035-1497
Country	:	US
Telephone Number	:	440-934-5966
Fax Number	:	440-934-2408

Provider Business Practice Location Address
First Line	:	5064 WATERFORD DR
Second Line	:
City	:	SHEFFIELD VILLAGE
State	:	OH
Zip	:	44035-1497
Country	:	US
Telephone Number	:	440-934-5966
Fax Number	:	440-934-2408

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

Provider Enumeration Date	:	04/26/2007
Last Update Date	:	07/08/2007

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