Provider Demographics
NPI:1801390406
Name:DIANE E VASQUEZ DDS LLC
Entity Type:Organization
Organization Name:DIANE E VASQUEZ DDS LLC
Other - Org Name:OLIVE FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:VASQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:213-915-1661
Mailing Address - Street 1:1635 CLAYTON SPUR CT
Mailing Address - Street 2:
Mailing Address - City:ELLISVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63011-2012
Mailing Address - Country:US
Mailing Address - Phone:213-915-1661
Mailing Address - Fax:
Practice Address - Street 1:2690 GRAVOIS RD
Practice Address - Street 2:
Practice Address - City:HIGH RIDGE
Practice Address - State:MO
Practice Address - Zip Code:63049-2508
Practice Address - Country:US
Practice Address - Phone:636-692-5803
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-20
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223G0001X
MO2018002617261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty