Healthcare Provider Details

I. General information

NPI: 1053697128
Provider Name (Legal Business Name): STEVENSON AND COHEN, A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2011
Last Update Date: 11/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 ROTARY WAY
VALLEJO CA
94591-8475
US

IV. Provider business mailing address

29 ROTARY WAY
VALLEJO CA
94591-8475
US

V. Phone/Fax

Practice location:
  • Phone: 707-554-1764
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number StateCA

VIII. Authorized Official

Name: MARK D STEVENSON
Title or Position: SECRETARY
Credential: DDS
Phone: 707-544-1764