=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366741498
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KRIS A. STEGMANN, D.D.S., P.L.L.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2011
-----------------------------------------------------
Last Update Date | 11/25/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 540 S. GARFIELD AVE
-----------------------------------------------------
City | TRAVERSE CITY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49686
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-947-4141
-----------------------------------------------------
Fax | 231-947-4528
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 540 S. GARFIELD AVE
-----------------------------------------------------
City | TRAVERSE CITY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49686
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-947-4141
-----------------------------------------------------
Fax | 231-947-4528
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KRIS A. STEGMANN
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 231-947-4141
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 2901016037
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------