Provider Demographics
NPI:1154375327
Name:CRATER, DIANE VAVRIK (DDS)
Entity type:Individual
Prefix:DR
First Name:DIANE
Middle Name:VAVRIK
Last Name:CRATER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8063 HADLEY AVE S
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55016-2652
Mailing Address - Country:US
Mailing Address - Phone:651-459-4894
Mailing Address - Fax:651-458-4940
Practice Address - Street 1:8063 HADLEY AVE S
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55016-2652
Practice Address - Country:US
Practice Address - Phone:651-459-4894
Practice Address - Fax:651-458-4940
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN96281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
1151079OtherMN TAX ID
2167963000OtherMN UI