Healthcare Provider Details

I. General information

NPI: 1447970140
Provider Name (Legal Business Name): DIANA G VILLARREAL DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2022
Last Update Date: 09/01/2022
Certification Date: 09/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9601 CHESTER AVE
CLEVELAND OH
44106-1666
US

IV. Provider business mailing address

27060 CEDAR RD
BEACHWOOD OH
44122-8103
US

V. Phone/Fax

Practice location:
  • Phone: 210-489-0421
  • Fax:
Mailing address:
  • Phone: 210-489-0421
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number004315
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: