Provider Demographics
NPI:1427383272
Name:WESTERN RESERVE CENTER FOR OROFACIAL AND COSMETIC SURGERY
Entity Type:Organization
Organization Name:WESTERN RESERVE CENTER FOR OROFACIAL AND COSMETIC SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:C
Authorized Official - Last Name:DIAMANTIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:216-227-3333
Mailing Address - Street 1:14700 DETROIT AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-4116
Mailing Address - Country:US
Mailing Address - Phone:216-227-3333
Mailing Address - Fax:216-226-3700
Practice Address - Street 1:14700 DETROIT AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-4116
Practice Address - Country:US
Practice Address - Phone:216-227-3333
Practice Address - Fax:216-226-3700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-13
Last Update Date:2009-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery