Provider Demographics
NPI:1003834466
Name:STEVENSON, PRETLOW LEE JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:PRETLOW
Middle Name:LEE
Last Name:STEVENSON
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3412 COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23707
Mailing Address - Country:US
Mailing Address - Phone:757-397-5611
Mailing Address - Fax:757-397-5573
Practice Address - Street 1:3412 COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23707
Practice Address - Country:US
Practice Address - Phone:757-397-5611
Practice Address - Fax:757-397-5573
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA5195122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
028450OtherAETNA DMO INSURANCE
322OtherDOMINION INSURANCE
VA4815115Medicaid
VA005864OtherBLUE CROSS INS
VA142470OtherCIGNA INS