Basic Information
| Provider Information | |||||||||
| NPI: | 1982706610 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEWART | ||||||||
| FirstName: | CATHLEEN | ||||||||
| MiddleName: | HELEN TAPP | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18601 VALLEY BOULEVARD | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098771818 | ||||||||
| FaxNumber: | 9097460400 | ||||||||
| Practice Location | |||||||||
| Address1: | 18601 VALLEY BOULEVARD | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9097460840 | ||||||||
| FaxNumber: | 9098775468 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 33379 | CA | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | G9805401 | 01 | CA | DELTA DENTAL | OTHER |