Provider Demographics
NPI:1316185150
Name:STEPHEN E NECHVATAL DMD PC
Entity Type:Organization
Organization Name:STEPHEN E NECHVATAL DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:LAUDERBAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-667-6855
Mailing Address - Street 1:1176 1/2 S LAPEER RD
Mailing Address - Street 2:STE B
Mailing Address - City:LAPEER
Mailing Address - State:MI
Mailing Address - Zip Code:48446-3098
Mailing Address - Country:US
Mailing Address - Phone:810-667-6855
Mailing Address - Fax:810-667-6875
Practice Address - Street 1:1176 1/2 S LAPEER RD
Practice Address - Street 2:STE B
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-3098
Practice Address - Country:US
Practice Address - Phone:810-667-6855
Practice Address - Fax:810-667-6875
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-02
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH117471223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI1901Medicare PIN