Provider Demographics
NPI:1700307071
Name:DIEGO, VIRGINIA (DDS)
Entity Type:Individual
Prefix:DR
First Name:VIRGINIA
Middle Name:
Last Name:DIEGO
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 1:2513 BELGRAVE AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-7103
Mailing Address - Country:US
Mailing Address - Phone:323-420-7323
Mailing Address - Fax:
Practice Address - Street 1:1601 N LONG BEACH BLVD
Practice Address - Street 2:
Practice Address - City:COMPTON
Practice Address - State:CA
Practice Address - Zip Code:90221-1610
Practice Address - Country:US
Practice Address - Phone:310-639-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-27
Last Update Date:2017-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101334122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist