Provider Demographics
NPI:1780431791
Name:MEDARIS, DIANE (RDH)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:MEDARIS
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:328 DERBY LN
Mailing Address - Street 2:
Mailing Address - City:HOPE MILLS
Mailing Address - State:NC
Mailing Address - Zip Code:28348-7556
Mailing Address - Country:US
Mailing Address - Phone:910-303-2048
Mailing Address - Fax:
Practice Address - Street 1:6238 ARDENNES ST
Practice Address - Street 2:
Practice Address - City:FT LIBERTY
Practice Address - State:NC
Practice Address - Zip Code:28307
Practice Address - Country:US
Practice Address - Phone:910-432-4821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-06
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7604124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist