Provider Demographics
NPI:1164416731
Name:STEVENS, TIMOTHY (DDS)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:STEVENS
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 1:1745 S IMPERIAL AVE STE 107
Mailing Address - Street 2:
Mailing Address - City:EL CENTRO
Mailing Address - State:CA
Mailing Address - Zip Code:92243-4243
Mailing Address - Country:US
Mailing Address - Phone:760-353-7603
Mailing Address - Fax:
Practice Address - Street 1:1745 S IMPERIAL AVE STE 107
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-4243
Practice Address - Country:US
Practice Address - Phone:760-353-7603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-09
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA597211223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery