1689963068 NPI number — DR. STAMATIOS GEORGE MANOLAKAS DENTINO M. D.

Table of content: DR. STAMATIOS GEORGE MANOLAKAS DENTINO M. D. (NPI 1689963068)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689963068 NPI number — DR. STAMATIOS GEORGE MANOLAKAS DENTINO M. D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DENTINO
Provider First Name:
STAMATIOS
Provider Middle Name:
GEORGE MANOLAKAS
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M. D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DENTINO
Provider Other First Name:
STAMATIOS
Provider Other Middle Name:
GEORGE
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1689963068
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/20/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3030 LATHAM DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SACRAMENTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95864-5646
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-219-7686
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30 N. 1900 E., RM. 5R-110
Provider Second Line Business Practice Location Address:
UNIVERSITY OF UTAH DEPT. OF PSYCHIATRY
Provider Business Practice Location Address City Name:
SALT LAKE CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84132-2502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-581-4096
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/06/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  8405889-1205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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