Provider Demographics
NPI:1386225969
Name:ROSENBERG, STACY
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:ROSENBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 S HEATH RD APT 2097
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93314-4830
Mailing Address - Country:US
Mailing Address - Phone:585-739-2888
Mailing Address - Fax:
Practice Address - Street 1:1710 CALLOWAY DR
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93312-2824
Practice Address - Country:US
Practice Address - Phone:661-515-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-15
Last Update Date:2024-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
CA1109651223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program