Healthcare Provider Details

I. General information

NPI: 1972047470
Provider Name (Legal Business Name): MS. ELIZABETH LAURA STEVENS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2016
Last Update Date: 12/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 STILLWATER AVE
BANGOR ME
04401-3984
US

IV. Provider business mailing address

14 DIAMOND MATCH RD
MILO ME
04463-1756
US

V. Phone/Fax

Practice location:
  • Phone: 207-941-6550
  • Fax:
Mailing address:
  • Phone: 207-941-6550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122400000X
TaxonomyDenturist
License NumberDTR5532
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: