Provider Demographics
NPI:1003819004
Name:STEVENS, MARY BERNONA (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:BERNONA
Last Name:STEVENS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1172 NIXON AVE NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49534-3638
Mailing Address - Country:US
Mailing Address - Phone:616-453-0644
Mailing Address - Fax:616-453-0640
Practice Address - Street 1:1172 NIXON AVE NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49544-3638
Practice Address - Country:US
Practice Address - Phone:616-453-0644
Practice Address - Fax:616-453-0640
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI128491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice