=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417027251
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STEVENSON DENTAL CLINIC FOR CHILDREN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2006
-----------------------------------------------------
Last Update Date | 10/01/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11165 LA QUINTA PLACE
-----------------------------------------------------
City | EL PASO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79936
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 915-591-1999
-----------------------------------------------------
Fax | 915-591-3201
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11165 LA QUINTA PLACE
-----------------------------------------------------
City | EL PASO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79936
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 915-591-1999
-----------------------------------------------------
Fax | 915-591-3201
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. EUGENE DAVIS STEVENSON JR.
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 915-591-1999
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 13513
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------