MEDICARE: GREGORY YIN SUE D.D.S.

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	DY28820	CA
2	1223P0221X	Pediatric Dentistry	DY28820	CA

General Provider Information

NPI Number	:	1700948528
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GREGORY YIN SUE D.D.S.

Provider Business Mailing Address
First Line	:	501 DEEP VALLEY DR STE 201
Second Line	:
City	:	ROLLING HILLS ESTATES
State	:	CA
Zip	:	90274-7608
Country	:	US
Telephone Number	:	310-377-5544
Fax Number	:

Provider Business Practice Location Address
First Line	:	501 DEEP VALLEY DR STE 201
Second Line	:
City	:	ROLLING HILLS ESTATES
State	:	CA
Zip	:	90274-7608
Country	:	US
Telephone Number	:	310-377-5544
Fax Number	:

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

Provider Enumeration Date	:	12/15/2006
Last Update Date	:	08/30/2007

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