Provider Demographics
NPI:1225246382
Name:FLEETWOOD, STEPHEN T (DDS)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:T
Last Name:FLEETWOOD
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 1:599 OLD BERWICK RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17815-2889
Mailing Address - Country:US
Mailing Address - Phone:570-784-8460
Mailing Address - Fax:570-784-3531
Practice Address - Street 1:599 OLD BERWICK RD
Practice Address - Street 2:
Practice Address - City:BLOOMSBURG
Practice Address - State:PA
Practice Address - Zip Code:17815-2889
Practice Address - Country:US
Practice Address - Phone:570-784-8460
Practice Address - Fax:570-784-3531
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS17774L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist