Provider Demographics
NPI:1447396502
Name:PAYNE, DARYL B (DDS)
Entity Type:Individual
Prefix:DR
First Name:DARYL
Middle Name:B
Last Name:PAYNE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 S FAIRMONT AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-3860
Mailing Address - Country:US
Mailing Address - Phone:209-334-0938
Mailing Address - Fax:209-334-4432
Practice Address - Street 1:525 S FAIRMONT AVE
Practice Address - Street 2:SUITE C
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-3860
Practice Address - Country:US
Practice Address - Phone:209-334-0938
Practice Address - Fax:209-334-4432
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA245851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice