Healthcare Provider Details

I. General information

NPI: 1033976626
Provider Name (Legal Business Name): NICHOLE SUN DDS, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2024
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1189 SWALLOW LN STE 200
SIMI VALLEY CA
93065-3157
US

IV. Provider business mailing address

588 CAMINO DEL LAGO
NEWBURY PARK CA
91320-6707
US

V. Phone/Fax

Practice location:
  • Phone: 805-522-3366
  • Fax:
Mailing address:
  • Phone: 805-792-5919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDDS54751
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: