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General NPI Number Information
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NPI Number | 1780431791
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Entity Type | Individual
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Provider Name | DIANE MEDARIS RDH
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Gender | Female
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Dates
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Enumeration Date | 05/06/2024
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Last Update Date | 05/06/2024
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Provider Practice Location Address
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Address Line | 6238 ARDENNES ST
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City | FT LIBERTY
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State | NC
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Zip | 28307
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Country | US
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Telephone | 910-432-4821
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Fax |
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Provider Business Mailing Address
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Address Line | 328 DERBY LN
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City | HOPE MILLS
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State | NC
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Zip | 28348-7556
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Country | US
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Telephone | 910-303-2048
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 124Q00000X
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Taxonomy Name | Dental Hygienist
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License Number | 7604
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License Number State | NC
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