Healthcare Provider Details

I. General information

NPI: 1336575646
Provider Name (Legal Business Name): DIANA MONTAGU CLINE D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2013
Last Update Date: 07/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2510 US HIGHWAY 1 S SUITE B, ATTN: DIANA CLINE
SAINT AUGUSTINE FL
32086-6100
US

IV. Provider business mailing address

2510 US HIGHWAY 1 S SUITE B, ATTN: DIANA CLINE
SAINT AUGUSTINE FL
32086-6100
US

V. Phone/Fax

Practice location:
  • Phone: 803-270-6665
  • Fax:
Mailing address:
  • Phone: 803-270-6665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDN21286
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: