Provider Demographics
NPI:1821099888
Name:DENTONI, STEPHANIE MARIE (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MARIE
Last Name:DENTONI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 579120
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95357-9120
Mailing Address - Country:US
Mailing Address - Phone:209-759-2533
Mailing Address - Fax:541-722-7090
Practice Address - Street 1:2216 N CALIFORNIA ST
Practice Address - Street 2:STE C
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-5533
Practice Address - Country:US
Practice Address - Phone:209-462-8346
Practice Address - Fax:209-462-8347
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA79037174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH72023Medicare UPIN
CA00A790371Medicare PIN