MEDICARE: DR. DIANE LEE BOVAL DDS

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	48630	CA

General Provider Information

NPI Number	:	1467554394
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DIANE LEE BOVAL DDS

Provider Business Mailing Address
First Line	:	651 S BEACH BLVD
Second Line	:
City	:	LA HABRA
State	:	CA
Zip	:	90631-5854
Country	:	US
Telephone Number	:	562-690-0110
Fax Number	:	866-817-3581

Provider Business Practice Location Address
First Line	:	651 S BEACH BLVD
Second Line	:
City	:	LA HABRA
State	:	CA
Zip	:	90631-5854
Country	:	US
Telephone Number	:	562-690-0110
Fax Number	:	866-817-3581

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

Provider Enumeration Date	:	09/01/2006
Last Update Date	:	11/16/2020

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