Healthcare Provider Details

I. General information

NPI: 1407878606
Provider Name (Legal Business Name): MARK R STEVENS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 03/22/2021
Certification Date: 03/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1430 JOHN WESLEY GILBERT DRIVE
AUGUSTA GA
30912-0004
US

IV. Provider business mailing address

1430 JOHN WESLEY GILBERT DRIVE GC-1012
AUGUSTA GA
30912-0001
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-9744
  • Fax: 706-721-6778
Mailing address:
  • Phone: 706-721-7913
  • Fax: 706-721-6778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberDN7757
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberDNGA000215
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberDDS25997
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberDN013387
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: