Provider Demographics
NPI:1134332174
Name:AZEVEDO, DIANN MARIE (DIANN AZEVEDO)
Entity Type:Individual
Prefix:
First Name:DIANN
Middle Name:MARIE
Last Name:AZEVEDO
Suffix:
Gender:F
Credentials:DIANN AZEVEDO
Other - Prefix:
Other - First Name:DIANN
Other - Middle Name:
Other - Last Name:AZEVEDO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RDH
Mailing Address - Street 1:5875 PACIFIC STREET
Mailing Address - Street 2:C-1
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95677-3146
Mailing Address - Country:US
Mailing Address - Phone:916-632-2554
Mailing Address - Fax:
Practice Address - Street 1:5875 PACIFIC STREET
Practice Address - Street 2:C-1
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95677-3146
Practice Address - Country:US
Practice Address - Phone:916-632-2554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHAP 15124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHO9342OtherDENTICAL