Provider Demographics
NPI:1972606903
Name:DIAMANTIS, NICHOLAS C (MD)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:C
Last Name:DIAMANTIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:NICHOLAS
Other - Middle Name:C
Other - Last Name:DIAMANTIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD DMD
Mailing Address - Street 1:14700 DETROIT AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107
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
Practice Address - Country:US
Practice Address - Phone:216-227-3333
Practice Address - Fax:216-226-3700
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2017-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350692921223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
G39879Medicare UPIN
OHDI0856761Medicare ID - Type Unspecified