Provider Demographics
NPI:1982649893
Name:VISCO, DIANA M (DDS)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:M
Last Name:VISCO
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 1:1260 LAKE ST
Mailing Address - Street 2:
Mailing Address - City:ROSELLE
Mailing Address - State:IL
Mailing Address - Zip Code:60172-3364
Mailing Address - Country:US
Mailing Address - Phone:630-980-6762
Mailing Address - Fax:
Practice Address - Street 1:1260 LAKE ST
Practice Address - Street 2:
Practice Address - City:ROSELLE
Practice Address - State:IL
Practice Address - Zip Code:60172-3364
Practice Address - Country:US
Practice Address - Phone:630-980-6762
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice