Provider Demographics
NPI:1326104134
Name:MASTRONARDI, DIANA LIVIA (DDS)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:LIVIA
Last Name:MASTRONARDI
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 1:20805 E 12 MILE RD
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-6502
Mailing Address - Country:US
Mailing Address - Phone:586-773-9660
Mailing Address - Fax:586-773-2640
Practice Address - Street 1:20805 E 12 MILE RD
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-6502
Practice Address - Country:US
Practice Address - Phone:586-773-9660
Practice Address - Fax:586-773-2640
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010177251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice