Provider Demographics
NPI:1184079931
Name:STEVEN DELISLE DENTAL CORPORATION
Entity type:Organization
Organization Name:STEVEN DELISLE DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:DEL ISLE
Authorized Official - Suffix:
Authorized Official - Credentials:DOS
Authorized Official - Phone:425-306-2579
Mailing Address - Street 1:462 N LINDEN DR
Mailing Address - Street 2:341
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90212-2247
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:462 N LINDEN DR
Practice Address - Street 2:341
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90212-2247
Practice Address - Country:US
Practice Address - Phone:425-306-2579
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-29
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56563122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty