Healthcare Provider Details

I. General information

NPI: 1922488352
Provider Name (Legal Business Name): SUSAN A SHEETS DDS A PROFESSIONAL DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2015
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 W GRAND AVE STE B2
EL SEGUNDO CA
90245-4243
US

IV. Provider business mailing address

2515 S WESTERN AVE STE 109
SAN PEDRO CA
90732-4643
US

V. Phone/Fax

Practice location:
  • Phone: 310-832-2657
  • Fax:
Mailing address:
  • Phone: 310-832-2657
  • Fax: 310-832-5164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code1223X2210X
TaxonomyOrofacial Pain Dentistry
License Number
License Number State

VIII. Authorized Official

Name: SUSAN ANN SHEETS
Title or Position: OWNER/PROVIDER
Credential: DDS
Phone: 310-525-0556