Provider Demographics
NPI:1609896729
Name:JOE, STEPHEN W (DMD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:W
Last Name:JOE
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 1:4824 GOODMAN RD
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-7950
Mailing Address - Country:US
Mailing Address - Phone:662-874-5917
Mailing Address - Fax:662-847-5998
Practice Address - Street 1:4824 GOODMAN ROAD
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654
Practice Address - Country:US
Practice Address - Phone:662-874-5917
Practice Address - Fax:662-874-5998
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2019-831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00060134Medicaid