Healthcare Provider Details

I. General information

NPI: 1205824240
Provider Name (Legal Business Name): EDWARD G. STEPHENS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 N WESTERN ST
MEXICO MO
65265-1909
US

IV. Provider business mailing address

303 N WESTERN ST
MEXICO MO
65265-1909
US

V. Phone/Fax

Practice location:
  • Phone: 573-581-1054
  • Fax: 573-581-1054
Mailing address:
  • Phone: 573-581-1054
  • Fax: 573-581-1054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number015959
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: