Provider Demographics
NPI:1548760630
Name:DEPIRRO, STEPHEN II (LD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:DEPIRRO
Suffix:II
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5791 JADEITE AVE
Mailing Address - Street 2:
Mailing Address - City:ALTA LOMA
Mailing Address - State:CA
Mailing Address - Zip Code:91737-2264
Mailing Address - Country:US
Mailing Address - Phone:253-370-8190
Mailing Address - Fax:
Practice Address - Street 1:740 AVENUE H STE 2
Practice Address - Street 2:
Practice Address - City:SEASIDE
Practice Address - State:OR
Practice Address - Zip Code:97138-6603
Practice Address - Country:US
Practice Address - Phone:833-909-1050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-15
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADN-60139787122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WADN-60139787OtherWASHINGTON STATE DEPARTMENT OF HEALTH
ORDT-DO-10130609OtherOREGON DEPARTMENT OF HEALTH