Provider Demographics
NPI:1841488657
Name:STEPHEN M. DENTLER, DO, PA
Entity type:Organization
Organization Name:STEPHEN M. DENTLER, DO, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:MAX
Authorized Official - Last Name:DENTLER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:361-579-1333
Mailing Address - Street 1:9410 NE ZAC LENTZ PKWY,
Mailing Address - Street 2:SUITE 202
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77904-3108
Mailing Address - Country:US
Mailing Address - Phone:361-579-1333
Mailing Address - Fax:361-579-1334
Practice Address - Street 1:9410 NE ZAC LENTZ PKWY,
Practice Address - Street 2:SUITE 202
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77904-3108
Practice Address - Country:US
Practice Address - Phone:361-579-1333
Practice Address - Fax:361-579-1334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-05
Last Update Date:2009-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4080208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX111836605Medicaid
TX0087CLOtherBLUE CROSS BLUE SHIELD
TX111836604Medicaid
TX5965594OtherAETNA
TX10049506OtherAMERIGROUP