Healthcare Provider Details

I. General information

NPI: 1174797708
Provider Name (Legal Business Name): W. FREDERICK STEPHENS,DDS,INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2008
Last Update Date: 02/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 S FAIR OAKS AVE SUITE #107
PASADENA CA
91105-2561
US

IV. Provider business mailing address

301 S FAIR OAKS AVE SUITE #107
PASADENA CA
91105-2561
US

V. Phone/Fax

Practice location:
  • Phone: 626-440-0099
  • Fax: 626-440-1002
Mailing address:
  • Phone: 626-440-0099
  • Fax: 626-440-1002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number34775
License Number StateCA

VIII. Authorized Official

Name: DR. WILLIAM FREDERICK STEPHENS
Title or Position: OWNER/PRESIDENT
Credential:
Phone: 626-440-0099