Provider Demographics
NPI:1205943495
Name:STEFANIDIS, MICHAEL ANTHONY (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:STEFANIDIS
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 1:7424 JACKSON DR #8
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92119
Mailing Address - Country:US
Mailing Address - Phone:619-463-5584
Mailing Address - Fax:619-463-5688
Practice Address - Street 1:7424 JACKSON DR #8
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92119
Practice Address - Country:US
Practice Address - Phone:619-463-5584
Practice Address - Fax:619-463-5688
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADB036699122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist