Provider Demographics
NPI:1275114969
Name:SHIMIZU, STEPHANIE ANN (DDS)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANN
Last Name:SHIMIZU
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3615 WASHINGTON ST UNIT A302
Mailing Address - Street 2:
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-2782
Mailing Address - Country:US
Mailing Address - Phone:925-787-6981
Mailing Address - Fax:
Practice Address - Street 1:UNIVERSITY PARK MC 0641
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90089-0001
Practice Address - Country:US
Practice Address - Phone:213-740-2851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-15
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
MADN18597351223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program