Provider Demographics
NPI:1255418471
Name:HINES, DIANE INGRAM (DDS)
Entity type:Individual
Prefix:DR
First Name:DIANE
Middle Name:INGRAM
Last Name:HINES
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19500 CUMBERLAND WAY
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48203-5501
Mailing Address - Country:US
Mailing Address - Phone:313-892-8762
Mailing Address - Fax:313-557-0277
Practice Address - Street 1:12645 GRATIOT AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48205-3952
Practice Address - Country:US
Practice Address - Phone:313-527-1140
Practice Address - Fax:313-527-9022
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI134701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice