Provider Demographics
NPI:1568042877
Name:VILLANUEVA, DIANA MARIA
Entity Type:Individual
Prefix:MS
First Name:DIANA
Middle Name:MARIA
Last Name:VILLANUEVA
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 1:1655 ELMWOOD AVE STE 215
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14620-3426
Mailing Address - Country:US
Mailing Address - Phone:585-636-0555
Mailing Address - Fax:
Practice Address - Street 1:1655 ELMWOOD AVE STE 215
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620-3426
Practice Address - Country:US
Practice Address - Phone:585-636-0555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-11
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY062615122300000X, 1223G0001X
PR34181223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program