MEDICARE: LAKEWOOD DENTAL GROUP, JEFFREY S ROSENTHAL DDS 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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1902327315
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKEWOOD DENTAL GROUP, JEFFREY S ROSENTHAL DDS INC

Provider Business Mailing Address
First Line	:	9571 MENTOR AVE
Second Line	:
City	:	MENTOR
State	:	OH
Zip	:	44060-4521
Country	:	US
Telephone Number	:	440-352-5700
Fax Number	:	440-352-5721

Provider Business Practice Location Address
First Line	:	17117 DETROIT AVE
Second Line	:
City	:	LAKEWOOD
State	:	OH
Zip	:	44107-3622
Country	:	US
Telephone Number	:	216-221-0300
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	AMY J SHREVES
Credential	:
Telephone Number	:	440-352-5700

Provider Enumeration Date	:	07/06/2017
Last Update Date	:	07/06/2017

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