=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053697128
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STEVENSON AND COHEN, A PROFESSIONAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2011
-----------------------------------------------------
Last Update Date | 11/02/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 29 ROTARY WAY
-----------------------------------------------------
City | VALLEJO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94591-8475
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-554-1764
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 29 ROTARY WAY
-----------------------------------------------------
City | VALLEJO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94591-8475
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SECRETARY
-----------------------------------------------------
Name | MARK D STEVENSON
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 707-544-1764
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223E0200X
-----------------------------------------------------
Taxonomy Name | Endodontics
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------