Provider Demographics
NPI:1518230044
Name:DAVIS, DIANE MARIE (RDH)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:MARIE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1512 EL PRADO AVE
Mailing Address - Street 2:
Mailing Address - City:LEMON GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:91945-4313
Mailing Address - Country:US
Mailing Address - Phone:619-772-2853
Mailing Address - Fax:
Practice Address - Street 1:4058 WILLOWS RD
Practice Address - Street 2:
Practice Address - City:ALPINE
Practice Address - State:CA
Practice Address - Zip Code:91901-1668
Practice Address - Country:US
Practice Address - Phone:619-445-1188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-14
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARHD10616124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist