Provider Demographics
NPI:1073640991
Name:STACEY, DIANE MARIE (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:MARIE
Last Name:STACEY
Suffix:
Gender:F
Credentials:DDS, MS
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:390 N STEPHANIE ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89014-8028
Mailing Address - Country:US
Mailing Address - Phone:702-947-7700
Mailing Address - Fax:702-932-7700
Practice Address - Street 1:390 N STEPHANIE ST
Practice Address - Street 2:SUITE 104
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89014-8028
Practice Address - Country:US
Practice Address - Phone:702-947-7700
Practice Address - Fax:702-932-7700
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV30831223P0221X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVS350/S622OtherSPECIALTY LICENSES