Provider Demographics
NPI:1568432409
Name:STEPHENSON, CHAD (DDS)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:
Last Name:STEPHENSON
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 1:409 NE GREENWOOD AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-4616
Mailing Address - Country:US
Mailing Address - Phone:541-318-1564
Mailing Address - Fax:
Practice Address - Street 1:409 NE GREENWOOD AVE STE 100
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-4616
Practice Address - Country:US
Practice Address - Phone:541-318-1564
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD85811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR023252Medicaid