Healthcare Provider Details

I. General information

NPI: 1891746715
Provider Name (Legal Business Name): SCOTT THOMAS STEVENSON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11970 SWEETWATER DR
GRAND LEDGE MI
48837-8199
US

IV. Provider business mailing address

11970 SWEETWATER DR
GRAND LEDGE MI
48837-8199
US

V. Phone/Fax

Practice location:
  • Phone: 517-627-2470
  • Fax: 517-627-7816
Mailing address:
  • Phone: 517-627-2470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number013629
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: