MEDICARE: STACEY NGOC DIEP DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	38901	TX
2	390200000X	Student in an Organized Health Care Education/Training Program
3	1223P0221X	Pediatric Dentistry	38901	TX

General Provider Information

NPI Number	:	1043940810
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACEY NGOC DIEP DDS

Provider Business Mailing Address
First Line	:	16903 W LAKE HOUSTON PKWY
Second Line	:
City	:	HUMBLE
State	:	TX
Zip	:	77346-4733
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	16903 W LAKE HOUSTON PKWY
Second Line	:
City	:	HUMBLE
State	:	TX
Zip	:	77346-4733
Country	:	US
Telephone Number	:	713-697-6453
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/14/2022
Last Update Date	:	01/15/2025

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