Healthcare Provider Details

I. General information

NPI: 1386103521
Provider Name (Legal Business Name): STEPHANIE LIANE SUE DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2019
Last Update Date: 05/24/2022
Certification Date: 05/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2277 MICHAEL DR STE 2
NEWBURY PARK CA
91320-3263
US

IV. Provider business mailing address

2277 MICHAEL DR STE 2
NEWBURY PARK CA
91320-3263
US

V. Phone/Fax

Practice location:
  • Phone: 805-498-2802
  • Fax:
Mailing address:
  • Phone: 805-728-5739
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDDS105961
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: