Provider Demographics
NPI:1457337248
Name:ALLEN, DIANE E (DDS)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:E
Last Name:ALLEN
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 1:4340 SHASTA DAM BLVD
Mailing Address - Street 2:
Mailing Address - City:SHASTA LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:96019-9420
Mailing Address - Country:US
Mailing Address - Phone:530-275-3077
Mailing Address - Fax:
Practice Address - Street 1:4340 SHASTA DAM BLVD
Practice Address - Street 2:
Practice Address - City:SHASTA LAKE
Practice Address - State:CA
Practice Address - Zip Code:96019-9420
Practice Address - Country:US
Practice Address - Phone:530-275-3077
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA268021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA26802OtherLICENSE NUMBER