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General NPI Number Information
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NPI Number | 1790037737
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Entity Type | Organization
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Legal Business Name | IMAGE DENTAL
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Dates
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Enumeration Date | 10/14/2012
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Last Update Date | 10/14/2012
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Provider Practice Location Address
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Address Line | 3453 BROOKSIDE RD SUITE A
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City | STOCKTON
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State | CA
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Zip | 95219-1788
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Country | US
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Telephone | 209-955-1500
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Fax | 209-955-1697
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Provider Business Mailing Address
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Address Line | 3453 BROOKSIDE RD SUITE A
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City | STOCKTON
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State | CA
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Zip | 95219-1788
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Country | US
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Telephone | 209-955-1500
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Fax | 209-955-1697
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Authorized Official
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Title or Position | OWNER
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Name | STEPHEN N NOZAKI
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Credential | DDS
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Telephone | 209-955-1500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 57165
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License Number State | CA
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