MEDICARE: STEPHEN VITAL DMD INC

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	305R00000X	Preferred Provider Organization	3270	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3270	OTHER	AZ	STATE OF ARIZONA

General Provider Information

NPI Number	:	1619134079
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STEPHEN VITAL DMD INC

Provider Business Mailing Address
First Line	:	3505 E BROWN RD
Second Line	:	SUITE 102
City	:	MESA
State	:	AZ
Zip	:	85213-5508
Country	:	US
Telephone Number	:	480-924-6169
Fax Number	:	480-924-1077

Provider Business Practice Location Address
First Line	:	3505 E BROWN RD
Second Line	:	SUITE 102
City	:	MESA
State	:	AZ
Zip	:	85213-5508
Country	:	US
Telephone Number	:	480-924-6169
Fax Number	:	480-924-1077

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. STEPHEN J VITAL
Credential	:	DMD
Telephone Number	:	480-924-6169

Provider Enumeration Date	:	05/21/2008
Last Update Date	:	05/21/2008

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Directions to “STEPHEN VITAL DMD INC ” Practice Location

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