Provider Demographics
NPI:1225145683
Name:EDE, DIANE (DMD, MHL)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:
Last Name:EDE
Suffix:
Gender:F
Credentials:DMD, MHL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3001 SAINT JOHNS BLVD
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-1884
Mailing Address - Country:US
Mailing Address - Phone:417-208-0759
Mailing Address - Fax:
Practice Address - Street 1:3001 SAINT JOHNS BLVD
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-1884
Practice Address - Country:US
Practice Address - Phone:417-208-0759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN134191223G0001X
MO20210056811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice