Provider Demographics
NPI:1578221214
Name:DIACENCO, OLESEA (RDH)
Entity Type:Individual
Prefix:
First Name:OLESEA
Middle Name:
Last Name:DIACENCO
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 VINEYARD RD APT 1002
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747-9126
Mailing Address - Country:US
Mailing Address - Phone:916-204-1214
Mailing Address - Fax:
Practice Address - Street 1:1420 BLUE OAKS BLVD
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95747-7358
Practice Address - Country:US
Practice Address - Phone:916-780-9688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-30
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33928124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist