=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265085443
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PATRYCJA STEWART DENTAL CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2019
-----------------------------------------------------
Last Update Date | 07/17/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6244 EL CAJON BLVD STE 6
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92115-3918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-583-2191
-----------------------------------------------------
Fax | 619-583-2192
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6244 EL CAJON BLVD STE 6
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92115-3918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-583-2191
-----------------------------------------------------
Fax | 619-583-2192
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | PATRYCJA STEWART
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 619-283-2191
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------