Provider Demographics
NPI:1245431352
Name:STEPHENS, DEREK MARCUS (DDS)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:MARCUS
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 1:113 W 86TH AVE
Mailing Address - Street 2:
Mailing Address - City:MERRILLIVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-7063
Mailing Address - Country:US
Mailing Address - Phone:219-736-2007
Mailing Address - Fax:219-736-2026
Practice Address - Street 1:113 W 86TH AVE
Practice Address - Street 2:
Practice Address - City:MERRILLIVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-7063
Practice Address - Country:US
Practice Address - Phone:219-736-2007
Practice Address - Fax:219-736-2026
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ININ12008151A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice