Provider Demographics
NPI:1073732640
Name:CHISMARICH, STEPHEN RICHARD (DDS)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:RICHARD
Last Name:CHISMARICH
Suffix:
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 1:310 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:MO
Mailing Address - Zip Code:63334-1561
Mailing Address - Country:US
Mailing Address - Phone:573-324-2238
Mailing Address - Fax:573-324-2239
Practice Address - Street 1:310 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:MO
Practice Address - Zip Code:63334-1561
Practice Address - Country:US
Practice Address - Phone:573-324-2238
Practice Address - Fax:573-324-2239
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO10993122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist