Provider Demographics
NPI:1053985754
Name:GORDILLO, STEPHANIE ELIZABETH (RDHAP)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ELIZABETH
Last Name:GORDILLO
Suffix:
Gender:F
Credentials:RDHAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 RUBY RD
Mailing Address - Street 2:
Mailing Address - City:LIVERMORE
Mailing Address - State:CA
Mailing Address - Zip Code:94550-5146
Mailing Address - Country:US
Mailing Address - Phone:510-703-5357
Mailing Address - Fax:
Practice Address - Street 1:606 RUBY RD
Practice Address - Street 2:
Practice Address - City:LIVERMORE
Practice Address - State:CA
Practice Address - Zip Code:94550-5146
Practice Address - Country:US
Practice Address - Phone:510-703-5357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-17
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHAP835124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist