Basic Information
| Provider Information | |||||||||
| NPI: | 1952602484 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STONE OAK MODERN DENTISTRY, PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | STONE OAK MODERN DENTISTRY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2860 MICHELLE FL 2 | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926061008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7143682077 | ||||||||
| FaxNumber: | 7143682092 | ||||||||
| Practice Location | |||||||||
| Address1: | 20821 US HIGHWAY 281 N STE 310 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782587597 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2104944488 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2010 | ||||||||
| LastUpdateDate: | 11/15/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BARNES | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER DOCTOR | ||||||||
| AuthorizedOfficialTelephone: | 2104944488 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DDS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.