Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 58572 | CA |
N | 1223D0001X | Dental Public Health | 58572 | CA |
N | 1223G0001X | General Practice | 58572 | CA |
N | 213EG0000X | General Practice | 58572 | CA |
N | 1223P0221X | Pediatric Dentist | 58572 | CA |
N | 1223P0300X | Periodontist | 58572 | CA |
NPI | 1366775793 |
---|---|
Provider Name | Stefanie Ann Reynolds |
First Address | Vista, CA 92084-5218 |
Second Address | Vista, CA 92084-5218 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/09/2009 |
Last Update Date | 12/12/2011 |