Provider Demographics
NPI:1841445699
Name:PRINCE, DOLORES DIANE (HYGIENIST)
Entity type:Individual
Prefix:
First Name:DOLORES
Middle Name:DIANE
Last Name:PRINCE
Suffix:
Gender:F
Credentials:HYGIENIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2405 NORTHWESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53404-2534
Mailing Address - Country:US
Mailing Address - Phone:262-886-0474
Mailing Address - Fax:262-886-1672
Practice Address - Street 1:2405 NORTHWESTERN AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53404-2534
Practice Address - Country:US
Practice Address - Phone:262-886-0474
Practice Address - Fax:262-886-1672
Is Sole Proprietor?:No
Enumeration Date:2008-11-20
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4517-16124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33820400Medicaid