Healthcare Provider Details

I. General information

NPI: 1053500959
Provider Name (Legal Business Name): STACIE DAWN FENDERSON DDS MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2007
Last Update Date: 10/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8689 FOLSOM BLVD
SACRAMENTO CA
95826
US

IV. Provider business mailing address

350 MEADOW GATE RD
MEADOW VISTA CA
95722
US

V. Phone/Fax

Practice location:
  • Phone: 916-381-7171
  • Fax: 916-381-1171
Mailing address:
  • Phone: 916-381-7171
  • Fax: 530-878-1470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number52724
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: