Healthcare Provider Details

I. General information

NPI: 1902463987
Provider Name (Legal Business Name): STEPHEN SETH CHILDERS DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2019
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIT 5024
APO AP
96319-5024
US

IV. Provider business mailing address

UNIT 5024
APO AP
96319-5024
US

V. Phone/Fax

Practice location:
  • Phone: 315-226-6700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number30.025800
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number30.025800
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: