Healthcare Provider Details

I. General information

NPI: 1255842340
Provider Name (Legal Business Name): STEPHEN BERTRAM INGRAM JR. DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 S 12TH ST
LEBANON PA
17042-6901
US

IV. Provider business mailing address

710 S 12TH STREET
LEBANON PA
17042
US

V. Phone/Fax

Practice location:
  • Phone: 717-274-2913
  • Fax: 717-274-0728
Mailing address:
  • Phone: 717-274-2913
  • Fax: 717-274-0728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDS020047L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: