MEDICARE: NICHOLE SUN DDS, MS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	DDS54751	CA

General Provider Information

NPI Number	:	1033976626
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHOLE SUN DDS, MS

Provider Business Mailing Address
First Line	:	588 CAMINO DEL LAGO
Second Line	:
City	:	NEWBURY PARK
State	:	CA
Zip	:	91320-6707
Country	:	US
Telephone Number	:	805-792-5919
Fax Number	:

Provider Business Practice Location Address
First Line	:	1189 SWALLOW LN STE 200
Second Line	:
City	:	SIMI VALLEY
State	:	CA
Zip	:	93065-3157
Country	:	US
Telephone Number	:	805-522-3366
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/01/2024
Last Update Date	:	06/23/2026

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