Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223E0200X | Endodontist | 26789 | CA |
NPI | 1083702674 |
---|---|
Provider Name | Dr. Matthew R. Stefanac |
First Address | Stockton, CA 95219-2355 |
Second Address | Stockton, CA 95219-2355 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/10/2006 |
Last Update Date | 08/03/2011 |