Provider Demographics
NPI:1477952182
Name:STRONG, STACEY DIANE (DDS)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:DIANE
Last Name:STRONG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2732 TREETOPS WAY
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-1646
Mailing Address - Country:US
Mailing Address - Phone:707-696-2147
Mailing Address - Fax:
Practice Address - Street 1:95 MONTGOMERY ADDRESS
Practice Address - Street 2:SUITE 106
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404
Practice Address - Country:US
Practice Address - Phone:707-545-5440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-19
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63751122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist