Provider Demographics
NPI:1528102134
Name:CARR, DIANA LYNN (RDHAP)
Entity type:Individual
Prefix:MS
First Name:DIANA
Middle Name:LYNN
Last Name:CARR
Suffix:
Gender:F
Credentials:RDHAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 264
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN BAUTISTA
Mailing Address - State:CA
Mailing Address - Zip Code:95045-0264
Mailing Address - Country:US
Mailing Address - Phone:831-623-4585
Mailing Address - Fax:831-623-4350
Practice Address - Street 1:141 LANG ST
Practice Address - Street 2:
Practice Address - City:SAN JUAN BAUTISTA
Practice Address - State:CA
Practice Address - Zip Code:95045-9400
Practice Address - Country:US
Practice Address - Phone:831-623-4585
Practice Address - Fax:831-623-4350
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHAP00135124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH00135-01OtherDENTI-CAL ID NO
CA167101OtherDELTA DENTAL BILLING NO.