Provider Demographics
NPI:1154751139
Name:DIEMANDEZI, CHARLENE (DDS)
Entity type:Individual
Prefix:
First Name:CHARLENE
Middle Name:
Last Name:DIEMANDEZI
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 1:708 W YOSEMITE AVE
Mailing Address - Street 2:
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93637-4563
Mailing Address - Country:US
Mailing Address - Phone:559-474-8200
Mailing Address - Fax:559-660-5375
Practice Address - Street 1:10011 BRIDGEPORT WAY SW STE 700
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-2350
Practice Address - Country:US
Practice Address - Phone:253-215-1101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA630771223G0001X
WADE606097351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice