Provider Demographics
NPI:1134293483
Name:HECKLEY, DIANE J (DDS)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:J
Last Name:HECKLEY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:J
Other - Last Name:CARTER-HECKLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:230 N MORTON ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47404-3964
Mailing Address - Country:US
Mailing Address - Phone:128-333-3330
Mailing Address - Fax:128-333-3067
Practice Address - Street 1:230 N MORTON ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404-3964
Practice Address - Country:US
Practice Address - Phone:128-333-3330
Practice Address - Fax:128-333-3067
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009390C1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200223800Medicaid