MEDICARE: DR. JEFFREY VANCE STANLEY 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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	33524	CA

General Provider Information

NPI Number	:	1194015594
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEFFREY VANCE STANLEY D.D.S

Provider Business Mailing Address
First Line	:	6465 N PALM AVE STE 105
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93704-1085
Country	:	US
Telephone Number	:	559-435-6465
Fax Number	:	559-435-5504

Provider Business Practice Location Address
First Line	:	6465 N PALM AVE STE 105
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93704-1085
Country	:	US
Telephone Number	:	559-435-6465
Fax Number	:	559-435-5504

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

Provider Enumeration Date	:	04/19/2011
Last Update Date	:	04/19/2011

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