Provider Demographics
NPI:1710545710
Name:LEE, DIANE PHAN (RDH)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:PHAN
Last Name:LEE
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:
Other - Last Name:PHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:6004 NE 51ST AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-1865
Mailing Address - Country:US
Mailing Address - Phone:503-821-9030
Mailing Address - Fax:
Practice Address - Street 1:9151 SE WOODSTOCK BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-5369
Practice Address - Country:US
Practice Address - Phone:503-433-2414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-04
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH7100124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist