Provider Demographics
NPI:1356897623
Name:CHAVIS, DIANE RENEE (D,DS)
Entity type:Individual
Prefix:DR
First Name:DIANE
Middle Name:RENEE
Last Name:CHAVIS
Suffix:
Gender:F
Credentials:D,DS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O BOX 58
Mailing Address - Street 2:
Mailing Address - City:ITTA BENA
Mailing Address - State:MS
Mailing Address - Zip Code:38941
Mailing Address - Country:US
Mailing Address - Phone:337-257-2388
Mailing Address - Fax:
Practice Address - Street 1:3700 BLUE SPRING RD NW STE F
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35810-3457
Practice Address - Country:US
Practice Address - Phone:256-852-9994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-28
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN104281223G0001X
AL6689-C11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice