Provider Demographics
NPI:1245968981
Name:DIEP, ALAN (DMD)
Entity type:Individual
Prefix:
First Name:ALAN
Middle Name:
Last Name:DIEP
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 MC DAVIS LOOP UNIT 3106
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32459-6787
Mailing Address - Country:US
Mailing Address - Phone:281-777-2856
Mailing Address - Fax:
Practice Address - Street 1:528 W BALDWIN RD UNIT B
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-3313
Practice Address - Country:US
Practice Address - Phone:850-215-0128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-10
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL273171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice