Provider Demographics
NPI:1174926281
Name:SUSTAITA, JOCELYNN VIDA (DMD)
Entity type:Individual
Prefix:DR
First Name:JOCELYNN
Middle Name:VIDA
Last Name:SUSTAITA
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 1:8137 DESERT JEWEL CIR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-7741
Mailing Address - Country:US
Mailing Address - Phone:702-524-2466
Mailing Address - Fax:
Practice Address - Street 1:141 E WILLOW ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-2633
Practice Address - Country:US
Practice Address - Phone:702-524-2466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-02
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA640801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice