Provider Demographics
NPI:1972683811
Name:MCLELLAN, DIANE MARY (DDS)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:MARY
Last Name:MCLELLAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20211 ECORSE ROAD
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180
Mailing Address - Country:US
Mailing Address - Phone:313-383-1125
Mailing Address - Fax:
Practice Address - Street 1:20211 ECORSE ROAD
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180
Practice Address - Country:US
Practice Address - Phone:313-383-1125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010149121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice