Provider Demographics
NPI:1790037737
Name:IMAGE DENTAL
Entity Type:Organization
Organization Name:IMAGE DENTAL
Other - Org Name:STEPHEN NOZAKI DDS, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:N
Authorized Official - Last Name:NOZAKI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:209-955-1500
Mailing Address - Street 1:3453 BROOKSIDE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-1788
Mailing Address - Country:US
Mailing Address - Phone:209-955-1500
Mailing Address - Fax:209-955-1697
Practice Address - Street 1:3453 BROOKSIDE RD
Practice Address - Street 2:SUITE A
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95219-1788
Practice Address - Country:US
Practice Address - Phone:209-955-1500
Practice Address - Fax:209-955-1697
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-14
Last Update Date:2012-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57165122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA57165OtherDDS