Provider Demographics
NPI:1528559861
Name:STEVENSON, CONNOR ROBERT (DMD)
Entity Type:Individual
Prefix:
First Name:CONNOR
Middle Name:ROBERT
Last Name:STEVENSON
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 1:5359 W VILLA RITA DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-1328
Mailing Address - Country:US
Mailing Address - Phone:661-713-8202
Mailing Address - Fax:
Practice Address - Street 1:3668 W ANTHEM WAY STE 162
Practice Address - Street 2:
Practice Address - City:ANTHEM
Practice Address - State:AZ
Practice Address - Zip Code:85086-0468
Practice Address - Country:US
Practice Address - Phone:623-551-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-22
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0100181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice