Provider Demographics
NPI:1366775793
Name:REYNOLDS, STEFANIE ANN (DMD)
Entity type:Individual
Prefix:
First Name:STEFANIE
Middle Name:ANN
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 VALE TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92084-5218
Mailing Address - Country:US
Mailing Address - Phone:760-407-1220
Mailing Address - Fax:760-414-3702
Practice Address - Street 1:1000 VALE TERRACE DR
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92084-5218
Practice Address - Country:US
Practice Address - Phone:760-407-1220
Practice Address - Fax:760-414-3702
Is Sole Proprietor?:No
Enumeration Date:2009-09-17
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58572122300000X, 1223D0001X, 1223G0001X, 1223P0221X, 1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223D0001XDental ProvidersDentistDental Public Health
No1223G0001XDental ProvidersDentistGeneral Practice
No1223P0221XDental ProvidersDentistPediatric Dentistry
No1223P0300XDental ProvidersDentistPeriodontics