Provider Demographics
NPI:1285836122
Name:BURR, DIANE LYNNE
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:LYNNE
Last Name:BURR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:LYNNE
Other - Last Name:HALE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1020 MARY ST
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-1930
Mailing Address - Country:US
Mailing Address - Phone:315-724-6907
Mailing Address - Fax:315-733-0791
Practice Address - Street 1:801 CYPRESS ST
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13440-2129
Practice Address - Country:US
Practice Address - Phone:315-339-6536
Practice Address - Fax:315-339-1746
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014461124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00474180Medicaid