Provider Demographics
NPI:1861652919
Name:BRANDLEIN, DIANE MARIE (DDS)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:MARIE
Last Name:BRANDLEIN
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 1:1917 BLACKHAWK BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BELOIT
Mailing Address - State:IL
Mailing Address - Zip Code:61080
Mailing Address - Country:US
Mailing Address - Phone:815-389-3605
Mailing Address - Fax:
Practice Address - Street 1:1917 BLACKHAWK BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH BELOIT
Practice Address - State:IL
Practice Address - Zip Code:61080
Practice Address - Country:US
Practice Address - Phone:815-389-3605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-12
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190193571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice