Provider Demographics
NPI:1417027251
Name:STEVENSON DENTAL CLINIC FOR CHILDREN
Entity Type:Organization
Organization Name:STEVENSON DENTAL CLINIC FOR CHILDREN
Other - Org Name:PROFESSIONAL ASSOCIATE
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:DAVIS
Authorized Official - Last Name:STEVENSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:915-591-1999
Mailing Address - Street 1:11165 LA QUINTA PLACE
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936
Mailing Address - Country:US
Mailing Address - Phone:915-591-1999
Mailing Address - Fax:915-591-3201
Practice Address - Street 1:11165 LA QUINTA PLACE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936
Practice Address - Country:US
Practice Address - Phone:915-591-1999
Practice Address - Fax:915-591-3201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX135131223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
D13513OtherBCBS
828328OtherUNITED CONCORDIA
G601421OtherDELTA CHIP
TX111009002Medicaid