Healthcare Provider Details

I. General information

NPI: 1396142154
Provider Name (Legal Business Name): GRACE SUN AE HUR DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2014
Last Update Date: 01/13/2022
Certification Date: 01/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2551 W BALL RD
ANAHEIM CA
92804-4001
US

IV. Provider business mailing address

770 THE CITY DR S STE 8450
ORANGE CA
92868-4970
US

V. Phone/Fax

Practice location:
  • Phone: 646-221-1217
  • Fax:
Mailing address:
  • Phone: 646-221-1217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number22DI02577200
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number103187
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number057915
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: