Provider Demographics
NPI:1114690849
Name:BATISTA, STEPHANIE MARC CASEQUIN
Entity Type:Individual
Prefix:
First Name:STEPHANIE MARC
Middle Name:CASEQUIN
Last Name:BATISTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6423 POINT ISABEL WAY
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89122-7640
Mailing Address - Country:US
Mailing Address - Phone:818-384-5407
Mailing Address - Fax:
Practice Address - Street 1:2250 S RANCHO DR STE 205
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-4456
Practice Address - Country:US
Practice Address - Phone:702-291-2031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-28
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV75481223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program