MEDICARE: MS. DIANA LYNN CARR RDHAP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	124Q00000X	Dental Hygienist	HAP00135	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	H00135-01	OTHER	CA	DENTI-CAL ID NO
2	167101	OTHER	CA	DELTA DENTAL BILLING NO.

General Provider Information

NPI Number	:	1528102134
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DIANA LYNN CARR RDHAP

Provider Business Mailing Address
First Line	:	PO BOX 264
Second Line	:
City	:	SAN JUAN BAUTISTA
State	:	CA
Zip	:	95045-0264
Country	:	US
Telephone Number	:	831-623-4585
Fax Number	:	831-623-4350

Provider Business Practice Location Address
First Line	:	141 LANG ST
Second Line	:
City	:	SAN JUAN BAUTISTA
State	:	CA
Zip	:	95045-9400
Country	:	US
Telephone Number	:	831-623-4585
Fax Number	:	831-623-4350

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/16/2007
Last Update Date	:	07/08/2007

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