Healthcare Provider Details

I. General information

NPI: 1932452638
Provider Name (Legal Business Name): STANKO BJELAJAC DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2012
Last Update Date: 08/03/2021
Certification Date: 08/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1795 EL CAMINO REAL STE 100
PALO ALTO CA
94306-1165
US

IV. Provider business mailing address

9225 W CHARLESTON BLVD APT 1007
LAS VEGAS NV
89117-7050
US

V. Phone/Fax

Practice location:
  • Phone: 310-753-9966
  • Fax:
Mailing address:
  • Phone: 310-753-9966
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberLL-307-12
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: