=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548808835
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELLE HANA STEPANEK DDS, MSD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/17/2019
-----------------------------------------------------
Last Update Date | 12/17/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 962 SEPULVEDA BLVD
-----------------------------------------------------
City | HARBOR CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90710-1405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-539-3245
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3063 LARKIN RD
-----------------------------------------------------
City | PEBBLE BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93953-2910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 831-233-1236
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | DDS103874
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------