Provider Demographics
NPI:1891924403
Name:WEIDLEY, DIANE RENEE (RDH)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:RENEE
Last Name:WEIDLEY
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HWY 264, MPP 388
Mailing Address - Street 2:P.O. BOX 4000
Mailing Address - City:POLACCA
Mailing Address - State:AZ
Mailing Address - Zip Code:86042
Mailing Address - Country:US
Mailing Address - Phone:928-737-6169
Mailing Address - Fax:928-737-6168
Practice Address - Street 1:HWY 264, MPP 388
Practice Address - Street 2:
Practice Address - City:POLACCA
Practice Address - State:AZ
Practice Address - Zip Code:86042
Practice Address - Country:US
Practice Address - Phone:928-737-6169
Practice Address - Fax:928-737-6168
Is Sole Proprietor?:No
Enumeration Date:2009-07-06
Last Update Date:2009-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDH16244124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist