Provider Demographics
NPI:1598775736
Name:STEPHENSON, JOHN MCKETHAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MCKETHAN
Last Name:STEPHENSON
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 1:402 DICEY FORD RD
Mailing Address - Street 2:STE E
Mailing Address - City:CAMDEN
Mailing Address - State:SC
Mailing Address - Zip Code:29020
Mailing Address - Country:US
Mailing Address - Phone:803-425-1644
Mailing Address - Fax:803-425-1640
Practice Address - Street 1:402 DICEY FORD RD
Practice Address - Street 2:STE E
Practice Address - City:CAMDEN
Practice Address - State:SC
Practice Address - Zip Code:29020
Practice Address - Country:US
Practice Address - Phone:803-425-1644
Practice Address - Fax:803-425-1640
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1902122300000X
SC2881223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered122300000XDental ProvidersDentist
Not Answered1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZ19025Medicaid