Provider Demographics
NPI:1033490388
Name:DIAMOND ONE DENTAL SERVICES, PLLC
Entity Type:Organization
Organization Name:DIAMOND ONE DENTAL SERVICES, PLLC
Other - Org Name:DENTAL FUN ZONE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KAYLI
Authorized Official - Middle Name:
Authorized Official - Last Name:COFFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-204-3557
Mailing Address - Street 1:1900 DURANCE
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:TX
Mailing Address - Zip Code:76210-0589
Mailing Address - Country:US
Mailing Address - Phone:702-204-3557
Mailing Address - Fax:
Practice Address - Street 1:10501 GATEWAY BLVD W
Practice Address - Street 2:SUITE 107
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-7934
Practice Address - Country:US
Practice Address - Phone:915-590-4600
Practice Address - Fax:915-590-4604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-31
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty