Provider Demographics
NPI:1538344569
Name:DENTAL PROFESSIONALS CLEVELAND-NOUNEH, INC
Entity type:Organization
Organization Name:DENTAL PROFESSIONALS CLEVELAND-NOUNEH, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:L
Authorized Official - Last Name:ULICHNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-345-9068
Mailing Address - Street 1:6315 PEARL RD STE 201
Mailing Address - Street 2:
Mailing Address - City:PARMA HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44130-3074
Mailing Address - Country:US
Mailing Address - Phone:330-345-9068
Mailing Address - Fax:440-824-4612
Practice Address - Street 1:4258 BELDEN VILLAGE MALL
Practice Address - Street 2:SPACE FC-17
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-2504
Practice Address - Country:US
Practice Address - Phone:330-492-4250
Practice Address - Fax:330-492-4255
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL PROFESSIONALS CLEVELAND-NOUNEH, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-09
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH19758122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2618724Medicaid