Provider Demographics
NPI:1073695516
Name:PENNINGTON, DIANE MANNING (DMD, MD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:MANNING
Last Name:PENNINGTON
Suffix:
Gender:F
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 HAWTHORN LN
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:GA
Mailing Address - Zip Code:31558-4026
Mailing Address - Country:US
Mailing Address - Phone:912-673-6545
Mailing Address - Fax:612-576-1846
Practice Address - Street 1:1891 GA HIGHWAY 40 E
Practice Address - Street 2:SUITE 1104
Practice Address - City:KINGSLAND
Practice Address - State:GA
Practice Address - Zip Code:31548-6572
Practice Address - Country:US
Practice Address - Phone:912-673-6545
Practice Address - Fax:912-576-1846
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0111961223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
H97236Medicare UPIN