MEDICARE: TIMOTHY STEVENS D.D.S

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	59721	CA

General Provider Information

NPI Number	:	1164416731
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIMOTHY STEVENS D.D.S

Provider Business Mailing Address
First Line	:	1745 S IMPERIAL AVE STE 107
Second Line	:
City	:	EL CENTRO
State	:	CA
Zip	:	92243-4243
Country	:	US
Telephone Number	:	760-353-7603
Fax Number	:

Provider Business Practice Location Address
First Line	:	1745 S IMPERIAL AVE STE 107
Second Line	:
City	:	EL CENTRO
State	:	CA
Zip	:	92243-4243
Country	:	US
Telephone Number	:	760-353-7603
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/09/2005
Last Update Date	:	06/28/2013

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