1336220144 NPI number — ROBERT O STEVENS DMD, PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336220144 NPI number — ROBERT O STEVENS DMD, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROBERT O STEVENS DMD, PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
BETHEL DENTAL GROUP
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336220144
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/13/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10572 W BUSINESS PARK LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOISE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83709-6797
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-375-5656
Provider Business Mailing Address Fax Number:
208-375-5928

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10572 W BUSINESS PARK LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83709-6797
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-375-5656
Provider Business Practice Location Address Fax Number:
208-375-5928
Provider Enumeration Date:
10/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
STEVENS
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
ORLO
Authorized Official Title or Position:
DENTIST OWNER
Authorized Official Telephone Number:
208-375-5656

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  D1807 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 43162 . This is a "REGENCE BLUE SHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 64709 . This is a "BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com