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General NPI Number Information
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NPI Number | 1992958722
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Entity Type | Organization
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Legal Business Name | STONE MOUNTAIN DENTAL
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Dates
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Enumeration Date | 10/24/2008
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Last Update Date | 10/24/2008
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Provider Practice Location Address
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Address Line | 4813 ROCKBRIDGE RD STE 26
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City | STONE MOUNTAIN
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State | GA
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Zip | 30083-4200
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Country | US
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Telephone | 404-292-8383
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Fax | 404-292-8344
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Provider Business Mailing Address
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Address Line | 4813 ROCKBRIDGE RD STE 26
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City | STONE MOUNTAIN
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State | GA
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Zip | 30083-4200
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Country | US
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Telephone | 404-292-8383
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Fax | 404-292-8344
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. SCHADALE STEVENS
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Credential | D.D.S.
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Telephone | 404-292-8383
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302R00000X
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Taxonomy Name | Health Maintenance Organization
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License Number | 012150
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License Number State | GA
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