Healthcare Provider Details

I. General information

NPI: 1255416459
Provider Name (Legal Business Name): STONE RANGARAJAN THAYER DMD, MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 08/11/2022
Certification Date: 08/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 MENGER SPGS STE 1200
BOERNE TX
78006-7220
US

IV. Provider business mailing address

134 MENGER SPGS STE 1200
BOERNE TX
78006-7220
US

V. Phone/Fax

Practice location:
  • Phone: 830-815-2480
  • Fax:
Mailing address:
  • Phone: 830-815-2480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN 20469
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberA137085
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberME 114524
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number22911
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: