Provider Demographics
NPI:1013391077
Name:DIENES, CAROLYN (OD)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:DIENES
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7200 HARRISON AVE # U265
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61112-1017
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1412 BUTTERFIELD RD
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-1031
Practice Address - Country:US
Practice Address - Phone:630-627-3001
Practice Address - Fax:630-627-3021
Is Sole Proprietor?:No
Enumeration Date:2015-07-18
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003909A152W00000X
IL046010862152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist