Provider Demographics
NPI:1609391820
Name:PURNOMO, STEPHANIE P (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:P
Last Name:PURNOMO
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7766 HUNTRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:CUPERTINO
Mailing Address - State:CA
Mailing Address - Zip Code:95014-4206
Mailing Address - Country:US
Mailing Address - Phone:626-715-7238
Mailing Address - Fax:
Practice Address - Street 1:20514 SARATOGA LOS GATOS RD STE A
Practice Address - Street 2:
Practice Address - City:SARATOGA
Practice Address - State:CA
Practice Address - Zip Code:95070-5970
Practice Address - Country:US
Practice Address - Phone:408-872-1900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-09
Last Update Date:2017-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA637041223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics