Healthcare Provider Details

I. General information

NPI: 1700822020
Provider Name (Legal Business Name): MICHAEL SHANE STEVENSON DMD, MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 10/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 STRATFORD RD SE
DECATUR AL
35601-6022
US

IV. Provider business mailing address

1401 STRATFORD RD SE
DECATUR AL
35601-6022
US

V. Phone/Fax

Practice location:
  • Phone: 256-355-1242
  • Fax: 256-355-1259
Mailing address:
  • Phone: 256-355-1242
  • Fax: 256-355-1259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number5063
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: