MEDICARE: DR. DIANE TRIMINGHAM NILES 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	34785	CA

General Provider Information

NPI Number	:	1679584700
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DIANE TRIMINGHAM NILES D.D.S.

Provider Business Mailing Address
First Line	:	76 DOCTORS PARK DR
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95405-6615
Country	:	US
Telephone Number	:	707-542-7577
Fax Number	:	707-542-7829

Provider Business Practice Location Address
First Line	:	76 DOCTORS PARK DR
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95405-6615
Country	:	US
Telephone Number	:	707-542-7577
Fax Number	:	707-542-7829

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

Provider Enumeration Date	:	08/11/2006
Last Update Date	:	01/11/2010

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