Provider Demographics
NPI:1053500959
Name:FENDERSON, STACIE DAWN (DDS MS)
Entity Type:Individual
Prefix:DR
First Name:STACIE
Middle Name:DAWN
Last Name:FENDERSON
Suffix:
Gender:F
Credentials:DDS MS
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Mailing Address - Street 1:350 MEADOW GATE RD
Mailing Address - Street 2:
Mailing Address - City:MEADOW VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:95722
Mailing Address - Country:US
Mailing Address - Phone:916-381-7171
Mailing Address - Fax:530-878-1470
Practice Address - Street 1:8689 FOLSOM BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95826
Practice Address - Country:US
Practice Address - Phone:916-381-7171
Practice Address - Fax:916-381-1171
Is Sole Proprietor?:No
Enumeration Date:2007-10-17
Last Update Date:2007-10-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CA527241223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics