Provider Demographics
NPI:1972942399
Name:IACOVELLI, DIANE CHEN (DMD)
Entity type:Individual
Prefix:DR
First Name:DIANE
Middle Name:CHEN
Last Name:IACOVELLI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 GLENDALE PL
Mailing Address - Street 2:
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-4816
Mailing Address - Country:US
Mailing Address - Phone:610-256-9862
Mailing Address - Fax:
Practice Address - Street 1:1869 DIXWELL AVE
Practice Address - Street 2:
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06514-3145
Practice Address - Country:US
Practice Address - Phone:203-408-2248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-19
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS039514122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist