MEDICARE: MINDY J 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	122300000X	Dentist	08173	IA

General Provider Information

NPI Number	:	1639398399
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MINDY J STEVENS D.D.S.

Provider Business Mailing Address
First Line	:	5708 SUNNYBROOK DR
Second Line	:
City	:	SIOUX CITY
State	:	IA
Zip	:	51106-4249
Country	:	US
Telephone Number	:	712-274-2338
Fax Number	:	712-274-8056

Provider Business Practice Location Address
First Line	:	5708 SUNNYBROOK DR
Second Line	:
City	:	SIOUX CITY
State	:	IA
Zip	:	51106-4249
Country	:	US
Telephone Number	:	712-274-2338
Fax Number	:	712-274-8056

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

Provider Enumeration Date	:	04/24/2007
Last Update Date	:	11/23/2007

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