Healthcare Provider Details

I. General information

NPI: 1447536578
Provider Name (Legal Business Name): STEVENS DENTAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2011
Last Update Date: 11/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 EAST 3RD AVENUE SOUTH
CAVALIER ND
58220
US

IV. Provider business mailing address

PO BOX 635
CAVALIER ND
58220-0635
US

V. Phone/Fax

Practice location:
  • Phone: 701-265-8777
  • Fax: 701-265-8778
Mailing address:
  • Phone: 701-265-8777
  • Fax: 701-265-8778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2100
License Number StateND

VIII. Authorized Official

Name: DR. STERLING R STEVENS
Title or Position: OWNER
Credential: DDS
Phone: 701-265-8777