Provider Demographics
NPI:1518057736
Name:STEVENS, GREGORY NICHOLAS (DMD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:NICHOLAS
Last Name:STEVENS
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:PO BOX 318
Mailing Address - Street 2:
Mailing Address - City:LISLE
Mailing Address - State:IL
Mailing Address - Zip Code:60532-0318
Mailing Address - Country:US
Mailing Address - Phone:630-725-3333
Mailing Address - Fax:630-725-3334
Practice Address - Street 1:5980 STATE ROUTE 53
Practice Address - Street 2:SUITE C
Practice Address - City:LISLE
Practice Address - State:IL
Practice Address - Zip Code:60532-3199
Practice Address - Country:US
Practice Address - Phone:630-725-3333
Practice Address - Fax:630-725-3334
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019016917//0210012381223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT38412Medicare UPIN
IL208516/K04516Medicare ID - Type Unspecified