Provider Demographics
NPI:1841300209
Name:LEVINE, STEPHEN DAVID (DDS PERIODONTIST)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:DAVID
Last Name:LEVINE
Suffix:
Gender:M
Credentials:DDS PERIODONTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11645 WILSHIRE BLVD.
Mailing Address - Street 2:STE 1001
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-6808
Mailing Address - Country:US
Mailing Address - Phone:310-208-7769
Mailing Address - Fax:310-820-6163
Practice Address - Street 1:11645 WILSHIRE BLVD.
Practice Address - Street 2:STE 1001
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-6808
Practice Address - Country:US
Practice Address - Phone:310-208-7769
Practice Address - Fax:310-820-6163
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20897122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist