Provider Demographics
NPI:1346913993
Name:GAN, DIANNE M (DMD)
Entity Type:Individual
Prefix:DR
First Name:DIANNE
Middle Name:M
Last Name:GAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6522 4TH AVE NE APT 16
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98115-6484
Mailing Address - Country:US
Mailing Address - Phone:860-796-5963
Mailing Address - Fax:
Practice Address - Street 1:1660 S COLUMBIAN WAY
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98108-1532
Practice Address - Country:US
Practice Address - Phone:800-329-8387
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-29
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA611859571223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty