Healthcare Provider Details

I. General information

NPI: 1518057736
Provider Name (Legal Business Name): GREGORY NICHOLAS STEVENS D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5980 STATE ROUTE 53 SUITE C
LISLE IL
60532-3199
US

IV. Provider business mailing address

PO BOX 318
LISLE IL
60532-0318
US

V. Phone/Fax

Practice location:
  • Phone: 630-725-3333
  • Fax: 630-725-3334
Mailing address:
  • Phone: 630-725-3333
  • Fax: 630-725-3334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number019016917//021001238
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: