MEDICARE: DIANA G TIRA RDHAP

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	124Q00000X	Dental Hygienist	352	CA

General Provider Information

NPI Number	:	1215214796
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANA G TIRA RDHAP

Provider Business Mailing Address
First Line	:	4467 AVENIDA DE LAS FLORES
Second Line	:
City	:	YORBA LINDA
State	:	CA
Zip	:	92886-2952
Country	:	US
Telephone Number	:	714-779-9171
Fax Number	:

Provider Business Practice Location Address
First Line	:	4467 AVENIDA DE LAS FLORES
Second Line	:
City	:	YORBA LINDA
State	:	CA
Zip	:	92886-2952
Country	:	US
Telephone Number	:	714-779-9171
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/10/2011
Last Update Date	:	11/10/2011

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