=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730220633
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STEPHENS AND GATEWOOD DDS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6315 CYPRESSWOOD DR
-----------------------------------------------------
City | SPRING
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77379-8208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-320-2000
-----------------------------------------------------
Fax | 281-320-0088
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6315 CYPRESSWOOD DR
-----------------------------------------------------
City | SPRING
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77379-8208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-320-2000
-----------------------------------------------------
Fax | 281-320-0088
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | INSURANCE COORDINATOR
-----------------------------------------------------
Name | MRS. KIMBERLY DEANN SWANN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 281-320-2000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 18848
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 14370
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------