Provider Demographics
NPI:1346399953
Name:SURBER, STEPHEN L (DMD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:L
Last Name:SURBER
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 1:401 HIGHWAY 11 S
Mailing Address - Street 2:
Mailing Address - City:ELLISVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39437-3103
Mailing Address - Country:US
Mailing Address - Phone:601-477-3771
Mailing Address - Fax:601-477-3747
Practice Address - Street 1:401 HIGHWAY 11 S
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MS
Practice Address - Zip Code:39437-3103
Practice Address - Country:US
Practice Address - Phone:601-477-3771
Practice Address - Fax:601-477-3747
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2366-871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015325Medicaid