Provider Demographics
NPI:1316280571
Name:AXELROD, DIANE JANE (DDS)
Entity type:Individual
Prefix:DR
First Name:DIANE
Middle Name:JANE
Last Name:AXELROD
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 1:5225 NESCONSET HWY STE 40
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-2060
Mailing Address - Country:US
Mailing Address - Phone:631-928-2830
Mailing Address - Fax:631-928-2915
Practice Address - Street 1:5225 NESCONSET HWY STE 40
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-2060
Practice Address - Country:US
Practice Address - Phone:631-928-2830
Practice Address - Fax:631-928-2915
Is Sole Proprietor?:No
Enumeration Date:2013-04-05
Last Update Date:2013-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042137-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice