Healthcare Provider Details

I. General information

NPI: 1700948528
Provider Name (Legal Business Name): GREGORY YIN SUE D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 08/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 DEEP VALLEY DR STE 201
ROLLING HILLS ESTATES CA
90274-7608
US

IV. Provider business mailing address

501 DEEP VALLEY DR STE 201
ROLLING HILLS ESTATES CA
90274-7608
US

V. Phone/Fax

Practice location:
  • Phone: 310-377-5544
  • Fax:
Mailing address:
  • Phone: 310-377-5544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDY28820
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDY28820
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: