Provider Demographics
NPI:1649428756
Name:ULRICH, DIANE E (DDS, MS)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:E
Last Name:ULRICH
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:
Other - First Name:BETSY
Other - Middle Name:
Other - Last Name:ULRICH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:400 N CHICAGO ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:IL
Mailing Address - Zip Code:62656-2016
Mailing Address - Country:US
Mailing Address - Phone:217-732-1073
Mailing Address - Fax:
Practice Address - Street 1:400 N. CHICAGO ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:IL
Practice Address - Zip Code:62656
Practice Address - Country:US
Practice Address - Phone:217-732-1073
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-03
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.024323122300000X
IL021.0018401223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist