Provider Demographics
NPI:1982877288
Name:CARUSO, DIANE V (DDS)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:V
Last Name:CARUSO
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 1:200 W FRONT ST STE 304
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-5067
Mailing Address - Country:US
Mailing Address - Phone:309-888-5454
Mailing Address - Fax:309-888-5896
Practice Address - Street 1:200 W FRONT ST STE 304
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-5067
Practice Address - Country:US
Practice Address - Phone:309-888-5454
Practice Address - Fax:309-888-5896
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-08
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice