Healthcare Provider Details

I. General information

NPI: 1194342386
Provider Name (Legal Business Name): DIANNE LEE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2020
Last Update Date: 12/19/2023
Certification Date: 12/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 KIEL AVE
KINNELON NJ
07405-2549
US

IV. Provider business mailing address

2404 VINCENT WAY
EAST NORRITON PA
19401-2058
US

V. Phone/Fax

Practice location:
  • Phone: 973-838-7888
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS042676
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDS042676
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number22DI02828300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: