Provider Demographics
NPI:1043232481
Name:STEPHENSON, MARK (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:STEPHENSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:MARK
Other - Middle Name:
Other - Last Name:STEPHENSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:500 MEDICAL CENTER BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-2800
Mailing Address - Country:US
Mailing Address - Phone:936-760-2200
Mailing Address - Fax:936-760-2226
Practice Address - Street 1:500 MEDICAL CENTER BLVD STE 110
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-2800
Practice Address - Country:US
Practice Address - Phone:936-760-2200
Practice Address - Fax:936-760-2226
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX162261223P0221X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX091158801Medicaid