Provider Demographics
NPI:1093860876
Name:HAUN, DIANE L (RDHAP)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:L
Last Name:HAUN
Suffix:
Gender:F
Credentials:RDHAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10736 JEFFERSON BLVD # 411
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90230-4933
Mailing Address - Country:US
Mailing Address - Phone:310-617-2302
Mailing Address - Fax:310-572-6062
Practice Address - Street 1:10736 JEFFERSON BLVD # 411
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230-4933
Practice Address - Country:US
Practice Address - Phone:310-617-2302
Practice Address - Fax:310-572-6062
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2009-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHAP 38124Q00000X
CA11303124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA11303OtherDELTA DENTAL
CAH00038-01Medicaid
147044OtherDELTA DENTAL OF CALIFORNI