=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255412953
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHEN B DEMMI DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2006
-----------------------------------------------------
Last Update Date | 09/26/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 437 SW PERIMETER GLEN
-----------------------------------------------------
City | LAKE CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-961-9669
-----------------------------------------------------
Fax | 386-752-3122
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 437 SW PERIMETER GLEN
-----------------------------------------------------
City | LAKE CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-961-9669
-----------------------------------------------------
Fax | 386-752-3122
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DN0013544
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DN13544
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------