Provider Demographics
NPI:1407964273
Name:RAULSTON, DIANA HOLTON (DDS)
Entity Type:Individual
Prefix:DR
First Name:DIANA
Middle Name:HOLTON
Last Name:RAULSTON
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 1:815 HOUSTON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76102
Mailing Address - Country:US
Mailing Address - Phone:817-877-3131
Mailing Address - Fax:817-877-4927
Practice Address - Street 1:815 HOUSTON ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76102
Practice Address - Country:US
Practice Address - Phone:817-877-3131
Practice Address - Fax:817-877-4927
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16088122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist