Provider Demographics
NPI:1558790915
Name:JOHN, STEPHEN ROBERT (DDS)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:ROBERT
Last Name:JOHN
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 1:205 DE ANZA BLVD. #41
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94402
Mailing Address - Country:US
Mailing Address - Phone:650-430-0186
Mailing Address - Fax:
Practice Address - Street 1:731 WALNUT ST
Practice Address - Street 2:
Practice Address - City:SAN CARLOS
Practice Address - State:CA
Practice Address - Zip Code:94070-3179
Practice Address - Country:US
Practice Address - Phone:650-430-0186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-06
Last Update Date:2024-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32858122300000X, 1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No122300000XDental ProvidersDentist