Provider Demographics
NPI:1144390246
Name:STEVENS, BRIDGET BOGGS (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRIDGET
Middle Name:BOGGS
Last Name:STEVENS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1226 OHIO AVE
Mailing Address - Street 2:
Mailing Address - City:DUNBAR
Mailing Address - State:WV
Mailing Address - Zip Code:25064-3020
Mailing Address - Country:US
Mailing Address - Phone:304-768-5616
Mailing Address - Fax:304-768-5617
Practice Address - Street 1:1226 OHIO AVE
Practice Address - Street 2:
Practice Address - City:DUNBAR
Practice Address - State:WV
Practice Address - Zip Code:25064-3020
Practice Address - Country:US
Practice Address - Phone:304-768-5616
Practice Address - Fax:304-768-5617
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV28831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV4005115000Medicaid