Provider Demographics
NPI:1780756031
Name:BAGNOLI, DIANE DANNER (DDS)
Entity type:Individual
Prefix:DR
First Name:DIANE
Middle Name:DANNER
Last Name:BAGNOLI
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 1:40 REDWOOD CT
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-3938
Mailing Address - Country:US
Mailing Address - Phone:765-448-4440
Mailing Address - Fax:765-447-1163
Practice Address - Street 1:500 N 26TH ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-2831
Practice Address - Country:US
Practice Address - Phone:765-448-1393
Practice Address - Fax:765-447-2263
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12008563A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice