Provider Demographics
NPI:1629746045
Name:STODDARD, ALIVIA JANE (DMD)
Entity Type:Individual
Prefix:
First Name:ALIVIA
Middle Name:JANE
Last Name:STODDARD
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12132 CONCORD CT
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-2161
Mailing Address - Country:US
Mailing Address - Phone:425-318-2081
Mailing Address - Fax:
Practice Address - Street 1:14101 NELSON AVE
Practice Address - Street 2:
Practice Address - City:LA PUENTE
Practice Address - State:CA
Practice Address - Zip Code:91746-2640
Practice Address - Country:US
Practice Address - Phone:425-318-2081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-31
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1068211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice