Provider Demographics
NPI:1437630068
Name:DIEPENHEIM, SOPHIE ROSE (DMD)
Entity Type:Individual
Prefix:
First Name:SOPHIE
Middle Name:ROSE
Last Name:DIEPENHEIM
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 1:548 NW HARMON BLVD
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97703-3022
Mailing Address - Country:US
Mailing Address - Phone:541-419-6567
Mailing Address - Fax:
Practice Address - Street 1:257 NE 2ND ST
Practice Address - Street 2:
Practice Address - City:PRINEVILLE
Practice Address - State:OR
Practice Address - Zip Code:97754-1910
Practice Address - Country:US
Practice Address - Phone:541-837-1709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-22
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE608840041223G0001X
ORD109241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice