Healthcare Provider Details

I. General information

NPI: 1538235767
Provider Name (Legal Business Name): ROBERT C STOCKDALE DDS MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 06/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3487 CENTRAL AVE
RIVERSIDE CA
92506-2115
US

IV. Provider business mailing address

9080 MILLIKEN AVE SUITE 100
RANCHO CUCAMONGA CA
91730-5558
US

V. Phone/Fax

Practice location:
  • Phone: 951-369-1001
  • Fax:
Mailing address:
  • Phone: 909-373-4898
  • Fax: 909-373-4899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number30716
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: