Provider Demographics
NPI:1578638854
Name:STEVENSON PEDIATRIC DENTISTRY P.C.
Entity Type:Organization
Organization Name:STEVENSON PEDIATRIC DENTISTRY P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:STEVENSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-302-7938
Mailing Address - Street 1:4019 W 12600 S
Mailing Address - Street 2:SUITE 200
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84096
Mailing Address - Country:US
Mailing Address - Phone:801-302-7938
Mailing Address - Fax:801-302-9409
Practice Address - Street 1:4019 W. 12600 S.
Practice Address - Street 2:SUITE 200
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84096
Practice Address - Country:US
Practice Address - Phone:801-302-7938
Practice Address - Fax:801-302-9409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5863508-99231223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty