Provider Demographics
NPI:1508955626
Name:STEPHENS, JON THOMAS (DMD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:THOMAS
Last Name:STEPHENS
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 1:38 ROUTE 87
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:CT
Mailing Address - Zip Code:06237
Mailing Address - Country:US
Mailing Address - Phone:860-228-0074
Mailing Address - Fax:
Practice Address - Street 1:147 EAST CENTER ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040
Practice Address - Country:US
Practice Address - Phone:860-643-9506
Practice Address - Fax:860-645-1707
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7625122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist