=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851345953
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK R STEVENSON D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6505 E 82ND ST
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46250-5538
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-849-6990
-----------------------------------------------------
Fax | 317-579-1404
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6505 E 82ND ST
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46250-1598
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-849-6990
-----------------------------------------------------
Fax | 317-579-1404
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 12010073A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------