Healthcare Provider Details

I. General information

NPI: 1073609996
Provider Name (Legal Business Name): DIANE TERESA PATKOWSKI DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 10/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

959 MYRTLE AVE
EUREKA CA
95501-1219
US

IV. Provider business mailing address

670 NINTH STREET SUITE 203
ARCATA CA
95521
US

V. Phone/Fax

Practice location:
  • Phone: 707-442-7078
  • Fax: 707-442-7298
Mailing address:
  • Phone: 707-826-8633
  • Fax: 707-826-8638

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number39694
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: