Healthcare Provider Details

I. General information

NPI: 1528102134
Provider Name (Legal Business Name): DIANA LYNN CARR RDHAP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 LANG ST
SAN JUAN BAUTISTA CA
95045-9400
US

IV. Provider business mailing address

PO BOX 264
SAN JUAN BAUTISTA CA
95045-0264
US

V. Phone/Fax

Practice location:
  • Phone: 831-623-4585
  • Fax: 831-623-4350
Mailing address:
  • Phone: 831-623-4585
  • Fax: 831-623-4350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberHAP00135
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: