Provider Demographics
NPI:1609515188
Name:KELCHNER, DIANE MARIE (EFDA)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:MARIE
Last Name:KELCHNER
Suffix:
Gender:F
Credentials:EFDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1132 CEDAR HEAD RD
Mailing Address - Street 2:
Mailing Address - City:SUGARLOAF
Mailing Address - State:PA
Mailing Address - Zip Code:18249-3518
Mailing Address - Country:US
Mailing Address - Phone:570-926-4145
Mailing Address - Fax:570-463-4493
Practice Address - Street 1:1084 ROUTE 315
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702
Practice Address - Country:US
Practice Address - Phone:570-704-4118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-02
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADF002745126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant