Provider Demographics
NPI:1568412153
Name:TOLENTINO, DIANA GRACE (DDS)
Entity Type:Individual
Prefix:DR
First Name:DIANA
Middle Name:GRACE
Last Name:TOLENTINO
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 1:8670 W CHEYENNE AVE
Mailing Address - Street 2:SUITE 150
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89129-7456
Mailing Address - Country:US
Mailing Address - Phone:702-341-1004
Mailing Address - Fax:702-341-1007
Practice Address - Street 1:8670 W CHEYENNE AVE
Practice Address - Street 2:SUITE 150
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89129-7456
Practice Address - Country:US
Practice Address - Phone:702-341-1004
Practice Address - Fax:702-341-1007
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV42981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN002202105Medicaid