Provider Demographics
NPI:1508350893
Name:DIBELLO, AMY LEE
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:LEE
Last Name:DIBELLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 S ENNIS ST
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-4716
Mailing Address - Country:US
Mailing Address - Phone:360-565-6128
Mailing Address - Fax:
Practice Address - Street 1:314 S ENNIS ST
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-4716
Practice Address - Country:US
Practice Address - Phone:360-565-6128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-19
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADH60658592124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WADH60658592OtherHYGIENIST
WADH60658592Medicaid