Provider Demographics
NPI:1871521492
Name:STEPHENS, DIANE PETERSEN (DMD)
Entity type:Individual
Prefix:DR
First Name:DIANE
Middle Name:PETERSEN
Last Name:STEPHENS
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:PO BOX 871128
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-0029
Mailing Address - Country:US
Mailing Address - Phone:770-465-3400
Mailing Address - Fax:770-465-3480
Practice Address - Street 1:5370 US HIGHWAY 78
Practice Address - Street 2:SUITE 720
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-3574
Practice Address - Country:US
Practice Address - Phone:770-465-3400
Practice Address - Fax:770-465-3480
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0098371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00265911AMedicaid
GA00265911AMedicaid