Provider Demographics
NPI:1083374623
Name:STEVENS, TYRONE HAROLD
Entity Type:Individual
Prefix:
First Name:TYRONE
Middle Name:HAROLD
Last Name:STEVENS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3129 TACOMA ST
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28208-2681
Mailing Address - Country:US
Mailing Address - Phone:601-336-2669
Mailing Address - Fax:
Practice Address - Street 1:3129 TACOMA ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28208-2681
Practice Address - Country:US
Practice Address - Phone:601-336-2669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-22
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC000008606466122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC000008606466Medicaid