Provider Demographics
NPI:1376728782
Name:DIEHL, ROSELLEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROSELLEN
Middle Name:
Last Name:DIEHL
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:PO BOX 400
Mailing Address - Street 2:DEUEL VOCATIONAL INSTITUTION
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95378-0400
Mailing Address - Country:US
Mailing Address - Phone:209-830-3884
Mailing Address - Fax:209-830-3917
Practice Address - Street 1:23500 KASSON ROAD
Practice Address - Street 2:DEUEL VOCATIONAL INSTITUTION
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95378-0400
Practice Address - Country:US
Practice Address - Phone:209-830-3884
Practice Address - Fax:209-830-3917
Is Sole Proprietor?:No
Enumeration Date:2008-01-03
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34949122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist