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11201 Shaker Blvd 136 Cleveland OH 44104-3869 | |
| (216) 368-7238 | |
| Not Available |
| Full Name | |
|---|---|
| Speciality | Dentist |
| Location | 11201 Shaker Blvd, Cleveland, Ohio |
| Authorized Official Name and Position | Andrew Matta (CHIEF MEDICAL OFFICER) |
| Authorized Official Contact | 7246742965 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
11 S Mill St New Castle PA 16101-3613 Ph: (724) 698-2500 | 11201 Shaker Blvd 136 Cleveland OH 44104-3869 Ph: (216) 368-7238 |
| NPI Number | 1790179992 |
|---|---|
| Provider Enumeration Date | 03/25/2015 |
| Last Update Date | 03/25/2015 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1790179992 | NPI | - | NPPES |
| 30023665 | Other | OH | LICENSE NUMBER |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 122300000X | Dentist | 30-023665 (Ohio) | Primary |
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