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General NPI Number Information
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NPI Number | 1568674620
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Entity Type | Organization
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Legal Business Name | STEPHENS & STEPHENS ORTHODONTICS
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Dates
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Enumeration Date | 05/03/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 3707 BROOKSIDE DRIVE
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City | TYLER
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State | TX
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Zip | 75701-8699
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Country | US
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Telephone | 903-561-7861
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Fax | 903-561-2431
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Provider Business Mailing Address
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Address Line | 3707 BROOKSIDE DRIVE
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City | TYLER
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State | TX
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Zip | 75701-8699
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Country | US
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Telephone | 903-561-7861
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Fax | 903-561-2431
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Authorized Official
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Title or Position | CO-OWNER
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Name | DR. MARVIN G STEPHENS JR.
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Credential | D.D.S., M.S.D.
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Telephone | 903-561-7861
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 9636
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 20671
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License Number State | TX
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