Provider Demographics
NPI:1225247794
Name:EVANS, DIANE MARIE (DDS)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:MARIE
Last Name:EVANS
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 1:15 HIGH TECH DR.
Mailing Address - Street 2:
Mailing Address - City:RUSH
Mailing Address - State:NY
Mailing Address - Zip Code:14543-9746
Mailing Address - Country:US
Mailing Address - Phone:585-321-1460
Mailing Address - Fax:585-321-1466
Practice Address - Street 1:15 HIGH TECH DR.
Practice Address - Street 2:
Practice Address - City:RUSH
Practice Address - State:NY
Practice Address - Zip Code:14543-9746
Practice Address - Country:US
Practice Address - Phone:585-321-1460
Practice Address - Fax:585-321-1466
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042296-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice