1710145446 NPI number — STOKES MOUNTAIN DENTAL GROUP, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710145446 NPI number — STOKES MOUNTAIN DENTAL GROUP, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STOKES MOUNTAIN DENTAL GROUP, PC
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:
Provider Other Organization Name Type Code:
6
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:
1710145446
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/03/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17000 RED HILL AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IRVINE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92614-5626
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-845-8890
Provider Business Mailing Address Fax Number:
949-474-1495

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9285 S CIMARRON RD
Provider Second Line Business Practice Location Address:
SUITE 125
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89178-2503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-433-5355
Provider Business Practice Location Address Fax Number:
702-360-3721
Provider Enumeration Date:
05/29/2008

Additional Information

Authorized Official

Authorized Official Last Name:
STOKES
Authorized Official First Name:
ROSS
Authorized Official Middle Name:
F
Authorized Official Title or Position:
OWNER DOCTOR
Authorized Official Telephone Number:
702-433-5355

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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