Provider Demographics
NPI:1013409713
Name:MAGNUS, DIANE (RDH)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:MAGNUS
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:
Other - Last Name:GREANYA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:380 N STATE RD
Mailing Address - Street 2:
Mailing Address - City:OTISVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48463-9486
Mailing Address - Country:US
Mailing Address - Phone:810-631-4524
Mailing Address - Fax:810-631-7041
Practice Address - Street 1:380 N STATE RD
Practice Address - Street 2:
Practice Address - City:OTISVILLE
Practice Address - State:MI
Practice Address - Zip Code:48463-9486
Practice Address - Country:US
Practice Address - Phone:810-631-4524
Practice Address - Fax:810-631-7041
Is Sole Proprietor?:No
Enumeration Date:2018-05-30
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist