Healthcare Provider Details

I. General information

NPI: 1366775793
Provider Name (Legal Business Name): STEFANIE ANN REYNOLDS D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2009
Last Update Date: 12/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 VALE TERRACE DR
VISTA CA
92084-5218
US

IV. Provider business mailing address

1000 VALE TERRACE DR
VISTA CA
92084-5218
US

V. Phone/Fax

Practice location:
  • Phone: 760-407-1220
  • Fax: 760-414-3702
Mailing address:
  • Phone: 760-407-1220
  • Fax: 760-414-3702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number58572
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number58572
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number58572
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number58572
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number58572
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: