=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306178629
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEANIE DIEP DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/11/2010
-----------------------------------------------------
Last Update Date | 02/11/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 39400 MURRIETA HOT SPRINGS RD SUITE 123-B
-----------------------------------------------------
City | MURRIETA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92563-7707
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-461-7470
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9533 CORTADA ST
-----------------------------------------------------
City | EL MONTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91733-1003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-500-7949
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 58730
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------