Healthcare Provider Details

I. General information

NPI: 1205551611
Provider Name (Legal Business Name): STEPHANIE HA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2022
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 S WESTMORELAND AVE STE 206
LOS ANGELES CA
90006-5671
US

IV. Provider business mailing address

2740 RIDGEPINE DR
LA CRESCENTA CA
91214-1438
US

V. Phone/Fax

Practice location:
  • Phone: 213-352-1166
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number108054
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: