=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326441718
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIANA CRAFT DDS INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/30/2014
-----------------------------------------------------
Last Update Date | 09/30/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1161 PUERTA DEL SOL SUITE 100
-----------------------------------------------------
City | SAN CLEMENTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92673-6311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-218-0433
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1161 PUERTA DEL SOL SUITE 100
-----------------------------------------------------
City | SAN CLEMENTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92673-6311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-218-0433
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ DENTIST
-----------------------------------------------------
Name | DIANA CRAFT
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 949-218-0433
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 58674
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------