=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174937270
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PAUL STEVENS DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2014
-----------------------------------------------------
Last Update Date | 05/10/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1385 N JACKSONMILL AVE
-----------------------------------------------------
City | KUNA
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83634-2042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-606-4816
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3646 E MARDIA ST
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83642-5481
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-400-4533
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | D-5149-PD
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | D10877
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 188794
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 9438
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------