Provider Demographics
NPI:1205824240
Name:STEPHENS, EDWARD G (DDS)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:G
Last Name:STEPHENS
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 1:303 N WESTERN ST
Mailing Address - Street 2:
Mailing Address - City:MEXICO
Mailing Address - State:MO
Mailing Address - Zip Code:65265-1909
Mailing Address - Country:US
Mailing Address - Phone:573-581-1054
Mailing Address - Fax:573-581-1054
Practice Address - Street 1:303 N WESTERN ST
Practice Address - Street 2:
Practice Address - City:MEXICO
Practice Address - State:MO
Practice Address - Zip Code:65265-1909
Practice Address - Country:US
Practice Address - Phone:573-581-1054
Practice Address - Fax:573-581-1054
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0159591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice