=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629565304
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHANIE NICHOLE BROWN DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2018
-----------------------------------------------------
Last Update Date | 09/30/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1203 S BEECHTREE ST
-----------------------------------------------------
City | GRAND HAVEN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49417-2839
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-850-3970
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 158 WESTOWN DR NW APT 301
-----------------------------------------------------
City | WALKER
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49534-3719
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-342-6410
-----------------------------------------------------
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 | 2901022860
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------