MEDICARE: STOCKTON DENTAL GROUP

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	122300000X	Dentist	39643	CA

General Provider Information

NPI Number	:	1356532626
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STOCKTON DENTAL GROUP

Provider Business Mailing Address
First Line	:	PO BOX 55368
Second Line	:
City	:	VALENCIA
State	:	CA
Zip	:	91385-0368
Country	:	US
Telephone Number	:	661-255-3130
Fax Number	:	661-451-5248

Provider Business Practice Location Address
First Line	:	1036 W ROBINHOOD DR
Second Line	:	STE 104
City	:	STOCKTON
State	:	CA
Zip	:	95207-5623
Country	:	US
Telephone Number	:	209-956-9650
Fax Number	:	209-956-9655

Authorized Official
Title or Position	:	OWNER
Name	:	SEAN SOHAIL HAKIMI
Credential	:	D.D.S.
Telephone Number	:	661-255-3130

Provider Enumeration Date	:	08/05/2007
Last Update Date	:	08/05/2007

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