Healthcare Provider Details

I. General information

NPI: 1427148642
Provider Name (Legal Business Name): GREGORY N. STEVENS D.M.D. LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5980 STATE ROUTE 53 SUITEC
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 Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number019016917//021001238
License Number StateIL

VIII. Authorized Official

Name: DR. GREGORY NICHOLAS STEVENS
Title or Position: PRESIDENT
Credential: D.M.D.
Phone: 630-725-3333