Provider Demographics
NPI:1235155060
Name:MYERS, STEPHEN J (DMD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:J
Last Name:MYERS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:MA
Mailing Address - Zip Code:02368-4151
Mailing Address - Country:US
Mailing Address - Phone:781-963-4900
Mailing Address - Fax:781-963-3911
Practice Address - Street 1:322 N MAIN ST
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:MA
Practice Address - Zip Code:02368-4151
Practice Address - Country:US
Practice Address - Phone:781-963-4900
Practice Address - Fax:781-963-3911
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA136601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAX11412OtherBLUECROSSBLUESHIELD
MAX05360OtherBLUECROSSBLUESHIELD