=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316236375
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANDRA SUKTALORDCHEEP PEPPER D.D.S.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2011
-----------------------------------------------------
Last Update Date | 07/25/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19255 GOLDEN VALLEY RD
-----------------------------------------------------
City | SANTA CLARITA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91387-1472
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-276-8755
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 318 SUGAR LOAF DR
-----------------------------------------------------
City | PALMDALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93551-7951
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-266-1192
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 62948
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------