Provider Demographics
NPI:1679873210
Name:DAVIS, STEPHANIE COLLEEN (HYG)
Entity Type:Individual
Prefix:MISS
First Name:STEPHANIE
Middle Name:COLLEEN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:HYG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:946 N WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-2427
Mailing Address - Country:US
Mailing Address - Phone:310-831-0735
Mailing Address - Fax:310-831-9784
Practice Address - Street 1:946 N WESTERN AVE
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-2427
Practice Address - Country:US
Practice Address - Phone:310-831-0735
Practice Address - Fax:310-831-9784
Is Sole Proprietor?:No
Enumeration Date:2010-10-29
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25202124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist