Healthcare Provider Details

I. General information

NPI: 1730362518
Provider Name (Legal Business Name): STEPHEN EDWARD HERSHEY D.D.S., M.S., L.L.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2007
Last Update Date: 12/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4468 W WALTON BLVD STE 2
WATERFORD MI
48329-4098
US

IV. Provider business mailing address

4468 W WALTON BLVD STE 2
WATERFORD MI
48329-4098
US

V. Phone/Fax

Practice location:
  • Phone: 248-674-5210
  • Fax: 248-674-6494
Mailing address:
  • Phone: 248-674-5210
  • Fax: 248-674-6494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number010797
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: