Provider Demographics
NPI:1265641815
Name:TOM, STEPHEN EDWARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:EDWARD
Last Name:TOM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1823 SHAW AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93611-4065
Mailing Address - Country:US
Mailing Address - Phone:559-322-1223
Mailing Address - Fax:559-322-5749
Practice Address - Street 1:1823 SHAW AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93611-4065
Practice Address - Country:US
Practice Address - Phone:559-322-1223
Practice Address - Fax:559-322-5749
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD29503122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist