Provider Demographics
NPI:1134143803
Name:STEPHEN, SIOBHAN MARIE (DMD MD)
Entity Type:Individual
Prefix:
First Name:SIOBHAN
Middle Name:MARIE
Last Name:STEPHEN
Suffix:
Gender:F
Credentials:DMD MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 TIMBER LANE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-7282
Mailing Address - Country:US
Mailing Address - Phone:802-860-6725
Mailing Address - Fax:802-864-1511
Practice Address - Street 1:44 TIMBER LANE
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-7282
Practice Address - Country:US
Practice Address - Phone:802-860-6725
Practice Address - Fax:802-864-0277
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT01600020931223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT49278OtherBLUE CROSS
VTVN2292Medicaid
VT102V106OtherMVP
VTVN2292Medicaid
U80525Medicare UPIN