Provider Demographics
NPI:1093883647
Name:GAULTNEY, DIANNA GAIL (DDS)
Entity Type:Individual
Prefix:DR
First Name:DIANNA
Middle Name:GAIL
Last Name:GAULTNEY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2105 KAOLIN ROAD
Mailing Address - Street 2:
Mailing Address - City:COBDEN
Mailing Address - State:IL
Mailing Address - Zip Code:62920
Mailing Address - Country:US
Mailing Address - Phone:618-833-7427
Mailing Address - Fax:
Practice Address - Street 1:207 N UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1445
Practice Address - Country:US
Practice Address - Phone:618-549-1646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice