Healthcare Provider Details

I. General information

NPI: 1902463987
Provider Name (Legal Business Name): STEPHEN SETH CHILDERS DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2019
Last Update Date: 10/26/2023
Certification Date: 10/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 BODIN CIR
TRAVIS AFB CA
94535-1809
US

IV. Provider business mailing address

337 BLUEBELL CT
VACAVILLE CA
95687-7312
US

V. Phone/Fax

Practice location:
  • Phone: 707-423-7085
  • Fax:
Mailing address:
  • Phone: 573-344-8138
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number30.025800
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: