Provider Demographics
NPI:1467480863
Name:STEPHENSON, GLEN K (DMD)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:K
Last Name:STEPHENSON
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 1:7480 NORTHVIEW ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-7232
Mailing Address - Country:US
Mailing Address - Phone:208-375-4041
Mailing Address - Fax:208-375-0225
Practice Address - Street 1:7480 NORTHVIEW ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-7232
Practice Address - Country:US
Practice Address - Phone:208-375-4041
Practice Address - Fax:208-375-0225
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD33381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8051747Medicaid