Provider Demographics
NPI:1689713125
Name:AMBERG-BORSELLINO, DIANE (DMD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:
Last Name:AMBERG-BORSELLINO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 N BEVERWYCK RD
Mailing Address - Street 2:
Mailing Address - City:LAKE HIAWATHA
Mailing Address - State:NJ
Mailing Address - Zip Code:07034-2294
Mailing Address - Country:US
Mailing Address - Phone:973-334-8258
Mailing Address - Fax:973-334-3617
Practice Address - Street 1:118 N BEVERWYCK RD
Practice Address - Street 2:
Practice Address - City:LAKE HIAWATHA
Practice Address - State:NJ
Practice Address - Zip Code:07034-2294
Practice Address - Country:US
Practice Address - Phone:973-334-8258
Practice Address - Fax:973-334-3617
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ200311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice