Provider Demographics
NPI:1083194948
Name:ESTRADA, STEPHANIE LYNN (RDH)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LYNN
Last Name:ESTRADA
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14885 SUTRO AVE
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90249-3640
Mailing Address - Country:US
Mailing Address - Phone:310-721-3329
Mailing Address - Fax:
Practice Address - Street 1:14885 SUTRO AVE
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90249-3640
Practice Address - Country:US
Practice Address - Phone:310-721-3329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-20
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24060124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty