Basic Information
| Provider Information | |||||||||
| NPI: | 1285836122 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURR | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | LYNNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HALE | ||||||||
| OtherFirstName: | DIANE | ||||||||
| OtherMiddleName: | LYNNE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1020 MARY ST | ||||||||
| Address2: | |||||||||
| City: | UTICA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 135011930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157246907 | ||||||||
| FaxNumber: | 3157330791 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 CYPRESS ST | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | NY | ||||||||
| PostalCode: | 134402129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153396536 | ||||||||
| FaxNumber: | 3153391746 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2007 | ||||||||
| LastUpdateDate: | 09/18/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | 014461 | NY | Y | Dental Providers | Dental Hygienist |
ID Information
| ID | Type | State | Issuer | Description | 00474180 | 05 | NY | MEDICAID |