Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 046010862 | IL |
N | 152W00000X | Optometrist | 18003909A | IN |
NPI | 1013391077 |
---|---|
Provider Name | Carolyn Dienes |
First Address | Rockford, IL 61112-1017 |
Second Address | Downers Grove, IL 60515-1031 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/07/2015 |
Last Update Date | 07/12/2021 |