Healthcare Provider Details

I. General information

NPI: 1912664210
Provider Name (Legal Business Name): HEATHER RAE STOCKTON RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2021
Last Update Date: 08/11/2022
Certification Date: 08/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 TROPICAL AVE
PASADENA CA
91107-1718
US

IV. Provider business mailing address

1225 TROPICAL AVE
PASADENA CA
91107-1718
US

V. Phone/Fax

Practice location:
  • Phone: 818-653-2403
  • Fax:
Mailing address:
  • Phone: 818-653-2403
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number33867
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number924
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: