Healthcare Provider Details

I. General information

NPI: 1104396969
Provider Name (Legal Business Name): MARK STIVERS, DDS, INC., P.S.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2018
Last Update Date: 12/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12728 19TH AVE SE STE 101
EVERETT WA
98208-6526
US

IV. Provider business mailing address

12728 19TH AVE SE STE 101
EVERETT WA
98208-6526
US

V. Phone/Fax

Practice location:
  • Phone: 425-224-4661
  • Fax: 425-224-4689
Mailing address:
  • Phone: 425-224-4661
  • Fax: 425-224-4689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: MARK W STIVERS
Title or Position: OWNER
Credential: DDS
Phone: 425-239-5600