=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821099888
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHANIE MARIE DENTONI M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/02/2005
-----------------------------------------------------
Last Update Date | 10/07/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2216 N CALIFORNIA ST STE C
-----------------------------------------------------
City | STOCKTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95204-5533
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-462-8346
-----------------------------------------------------
Fax | 209-462-8347
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 579120
-----------------------------------------------------
City | MODESTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95357-9120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-759-2533
-----------------------------------------------------
Fax | 541-722-7090
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | A79037
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------