Provider Demographics
NPI:1417571076
Name:DIEGO, STEPHANIE J (DDS, MPH)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:J
Last Name:DIEGO
Suffix:
Gender:F
Credentials:DDS, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1130 COFFEE RD STE 8A
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-4228
Mailing Address - Country:US
Mailing Address - Phone:209-566-1990
Mailing Address - Fax:
Practice Address - Street 1:1130 COFFEE RD STE 8A
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-4228
Practice Address - Country:US
Practice Address - Phone:209-225-9696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-29
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
CA107956122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program