Provider Demographics
NPI:1780778332
Name:NOGALO, DIANE GERISE (DDS)
Entity type:Individual
Prefix:DR
First Name:DIANE
Middle Name:GERISE
Last Name:NOGALO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:34900 LAKE SHORE BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:EASTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44095-2099
Mailing Address - Country:US
Mailing Address - Phone:440-954-8300
Mailing Address - Fax:440-954-8302
Practice Address - Street 1:34900 LAKE SHORE BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:EASTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44095-2099
Practice Address - Country:US
Practice Address - Phone:440-954-8300
Practice Address - Fax:440-954-8302
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH208781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice