MEDICARE: DR. DIANE GERISE NOGALO 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	20878	OH

General Provider Information

NPI Number	:	1780778332
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DIANE GERISE NOGALO D.D.S.

Provider Business Mailing Address
First Line	:	34900 LAKE SHORE BLVD
Second Line	:	SUITE 101
City	:	EASTLAKE
State	:	OH
Zip	:	44095-2099
Country	:	US
Telephone Number	:	440-954-8300
Fax Number	:	440-954-8302

Provider Business Practice Location Address
First Line	:	34900 LAKE SHORE BLVD
Second Line	:	SUITE 101
City	:	EASTLAKE
State	:	OH
Zip	:	44095-2099
Country	:	US
Telephone Number	:	440-954-8300
Fax Number	:	440-954-8302

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

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	07/08/2007

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