Healthcare Provider Details

I. General information

NPI: 1174194617
Provider Name (Legal Business Name): STEVENSON SMITH DMD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2021
Last Update Date: 07/06/2021
Certification Date: 07/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

911 COUNTRY CLUB RD STE 222
EUGENE OR
97401-6046
US

IV. Provider business mailing address

34313 DEERWOOD DR
EUGENE OR
97405-9662
US

V. Phone/Fax

Practice location:
  • Phone: 801-885-7639
  • Fax:
Mailing address:
  • Phone: 801-885-7639
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: STEVENSON SMITH
Title or Position: OWNER
Credential: DMD
Phone: 801-885-7639