Provider Demographics
NPI:1770786907
Name:PIELAGO, JEROME S (DMD)
Entity type:Individual
Prefix:
First Name:JEROME
Middle Name:S
Last Name:PIELAGO
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 1:4625 FARRIER WAY
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747-8910
Mailing Address - Country:US
Mailing Address - Phone:916-780-1698
Mailing Address - Fax:
Practice Address - Street 1:1300 LINCOLN WAY
Practice Address - Street 2:SUITE #D
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95603
Practice Address - Country:US
Practice Address - Phone:530-885-1931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA503461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice