MEDICARE: DR. STEVEN RUSSELL CLEVENGER DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	34559	CA

General Provider Information

NPI Number	:	1588790190
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STEVEN RUSSELL CLEVENGER DDS

Provider Business Mailing Address
First Line	:	1016 SOQUEL AVE
Second Line	:
City	:	SANTA CRUZ
State	:	CA
Zip	:	95062-2104
Country	:	US
Telephone Number	:	831-426-0598
Fax Number	:	831-426-0585

Provider Business Practice Location Address
First Line	:	1016 SOQUEL AVE
Second Line	:
City	:	SANTA CRUZ
State	:	CA
Zip	:	95062-2104
Country	:	US
Telephone Number	:	831-426-0598
Fax Number	:	831-426-0585

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/26/2007
Last Update Date	:	07/08/2007

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