Healthcare Provider Details

I. General information

NPI: 1558764845
Provider Name (Legal Business Name): RUSSELL JOHN STEPHENS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: RUSSELL STEPHENS

II. Dates (important events)

Enumeration Date: 10/01/2014
Last Update Date: 07/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

424 N. WARREN AVE.
NEWPORT WA
99156
US

IV. Provider business mailing address

424 N. WARREN AVE.
NEWPORT WA
99156
US

V. Phone/Fax

Practice location:
  • Phone: 509-447-5960
  • Fax: 575-572-2259
Mailing address:
  • Phone: 509-447-5960
  • Fax: 575-572-2259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number9051997-9921
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDE60851015
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: