MEDICARE: DR. MICHAEL L. STEVENS D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	5491	UT

General Provider Information

NPI Number	:	1619170867
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL L. STEVENS D.D.S.

Provider Business Mailing Address
First Line	:	2200 E 4500 S
Second Line	:	SUITE 250
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84117-4437
Country	:	US
Telephone Number	:	801-278-5822
Fax Number	:

Provider Business Practice Location Address
First Line	:	2200 E 4500 S
Second Line	:	SUITE 250
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84117-4437
Country	:	US
Telephone Number	:	801-278-5822
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/06/2007
Last Update Date	:	07/08/2007

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