Provider Demographics
NPI:1144694886
Name:DIAKONOV, GINA ADELLE (RDH, BSDH)
Entity type:Individual
Prefix:MS
First Name:GINA
Middle Name:ADELLE
Last Name:DIAKONOV
Suffix:
Gender:F
Credentials:RDH, BSDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48208-2576
Mailing Address - Country:US
Mailing Address - Phone:313-494-6962
Mailing Address - Fax:313-494-6709
Practice Address - Street 1:2700 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48208-2576
Practice Address - Country:US
Practice Address - Phone:313-494-6962
Practice Address - Fax:313-494-6709
Is Sole Proprietor?:No
Enumeration Date:2015-11-18
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902015970124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist