Provider Demographics
NPI:1528205309
Name:STEVENSON, MARK JOSEPH (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JOSEPH
Last Name:STEVENSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1618 W MILHAM AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-1230
Mailing Address - Country:US
Mailing Address - Phone:269-343-1522
Mailing Address - Fax:269-343-9744
Practice Address - Street 1:1618 W MILHAM AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-1230
Practice Address - Country:US
Practice Address - Phone:269-343-1522
Practice Address - Fax:269-343-9744
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-15
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901019566122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist