1063430718 NPI number — STEPHANIE M. DENTONI MD, INC

Table of content: (NPI 1063430718)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063430718 NPI number — STEPHANIE M. DENTONI MD, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STEPHANIE M. DENTONI MD, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CALIFORNIA VEIN & VASCULAR INSTITUTE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063430718
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/07/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 579120
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MODESTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95357-9120
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-759-2533
Provider Business Mailing Address Fax Number:
541-722-7090

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2216 N. CALIFORNIA ST. STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STOCKTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-462-8346
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/18/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DENTONI
Authorized Official First Name:
STEPHANIE
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
209-462-8346

Provider Taxonomy Codes

  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)