Provider Demographics
NPI:1376722033
Name:RAY, DIANE MARIE (DDS MS)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:MARIE
Last Name:RAY
Suffix:
Gender:F
Credentials:DDS MS
Other - Prefix:DR
Other - First Name:DIANE
Other - Middle Name:MARIE
Other - Last Name:RAY ENGROFF
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD MS
Mailing Address - Street 1:101 KENNEDY ST
Mailing Address - Street 2:
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16801-7806
Mailing Address - Country:US
Mailing Address - Phone:814-235-9998
Mailing Address - Fax:814-235-9998
Practice Address - Street 1:2565 PARK CENTER BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16801-3007
Practice Address - Country:US
Practice Address - Phone:814-308-9504
Practice Address - Fax:814-954-7723
Is Sole Proprietor?:No
Enumeration Date:2007-10-30
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0354371223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1024618970Medicare NSC