Healthcare Provider Details

I. General information

NPI: 1386225969
Provider Name (Legal Business Name): STACY ROSENBERG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2021
Last Update Date: 12/21/2024
Certification Date: 12/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1710 CALLOWAY DR
BAKERSFIELD CA
93312-2824
US

IV. Provider business mailing address

250 S HEATH RD APT 2097
BAKERSFIELD CA
93314-4830
US

V. Phone/Fax

Practice location:
  • Phone: 661-515-1234
  • Fax:
Mailing address:
  • Phone: 585-739-2888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number110965
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: