MEDICARE: DR. DIANE RENEE CHAVIS D,.D.S

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	10428	TN
2	1223G0001X	General Practice Dentistry	6689-C1	AL

General Provider Information

NPI Number	:	1356897623
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DIANE RENEE CHAVIS D,.D.S

Provider Business Mailing Address
First Line	:	P.O BOX 58
Second Line	:
City	:	ITTA BENA
State	:	MS
Zip	:	38941
Country	:	US
Telephone Number	:	337-257-2388
Fax Number	:

Provider Business Practice Location Address
First Line	:	3700 BLUE SPRING RD NW STE F
Second Line	:
City	:	HUNTSVILLE
State	:	AL
Zip	:	35810-3457
Country	:	US
Telephone Number	:	256-852-9994
Fax Number	:

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

Provider Enumeration Date	:	08/28/2016
Last Update Date	:	07/17/2019

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