Provider Demographics
NPI:1134234636
Name:DIAK, DAVID ALAN (DMD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:ALAN
Last Name:DIAK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1911 JOHNSON RD
Mailing Address - Street 2:SUITE # 1
Mailing Address - City:GRANITE CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62040-3835
Mailing Address - Country:US
Mailing Address - Phone:618-877-3434
Mailing Address - Fax:618-877-3434
Practice Address - Street 1:1911 JOHNSON RD
Practice Address - Street 2:SUITE # 1
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-3835
Practice Address - Country:US
Practice Address - Phone:618-877-3434
Practice Address - Fax:618-877-3434
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice