Provider Demographics
NPI:1255842340
Name:INGRAM, STEPHEN BERTRAM JR (DMD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:BERTRAM
Last Name:INGRAM
Suffix:JR
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 1:710 S 12TH STREET
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17042
Mailing Address - Country:US
Mailing Address - Phone:717-274-2913
Mailing Address - Fax:717-274-0728
Practice Address - Street 1:710 S 12TH ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-6901
Practice Address - Country:US
Practice Address - Phone:717-274-2913
Practice Address - Fax:717-274-0728
Is Sole Proprietor?:No
Enumeration Date:2017-10-17
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS020047L1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics