Provider Demographics
NPI:1598469819
Name:WEISMAN, STACY LYNN (RDH)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:LYNN
Last Name:WEISMAN
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 1:32767 PRESIDIO HILLS LN
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:CA
Mailing Address - Zip Code:92596-8435
Mailing Address - Country:US
Mailing Address - Phone:717-201-6874
Mailing Address - Fax:
Practice Address - Street 1:32767 PRESIDIO HILLS LN
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:CA
Practice Address - Zip Code:92596-8435
Practice Address - Country:US
Practice Address - Phone:717-201-6874
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-29
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31713124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist