Healthcare Provider Details

I. General information

NPI: 1376722033
Provider Name (Legal Business Name): DIANE MARIE RAY DDS MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DIANE MARIE RAY ENGROFF DMD MS

II. Dates (important events)

Enumeration Date: 10/30/2007
Last Update Date: 02/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2565 PARK CENTER BLVD SUITE 300
STATE COLLEGE PA
16801-3007
US

IV. Provider business mailing address

101 KENNEDY ST
STATE COLLEGE PA
16801-7806
US

V. Phone/Fax

Practice location:
  • Phone: 814-308-9504
  • Fax: 814-954-7723
Mailing address:
  • Phone: 814-235-9998
  • Fax: 814-235-9998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDS035437
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: