MEDICARE: DIAMOND DENTAL, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1154290468
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIAMOND DENTAL, LLC

Provider Business Mailing Address
First Line	:	42104 N VENTURE DR UNIT 103
Second Line	:
City	:	ANTHEM
State	:	AZ
Zip	:	85086-3823
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	42104 N VENTURE DR UNIT 103
Second Line	:
City	:	ANTHEM
State	:	AZ
Zip	:	85086-3823
Country	:	US
Telephone Number	:	480-561-5693
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	VINCEN BATEMAN
Credential	:	DMD
Telephone Number	:	208-680-4203

Provider Enumeration Date	:	11/04/2025
Last Update Date	:	01/05/2026

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