Provider Demographics
NPI:1659744639
Name:GAO, SU (DDS)
Entity type:Individual
Prefix:
First Name:SU
Middle Name:
Last Name:GAO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:199 N EL CAMINO REAL
Mailing Address - Street 2:SUITE E
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-2803
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:199 N EL CAMINO REAL
Practice Address - Street 2:SUITE E
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-2803
Practice Address - Country:US
Practice Address - Phone:760-522-1136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-12
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41254122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist