Provider Demographics
NPI:1619170867
Name:STEVENS, MICHAEL L (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:L
Last Name:STEVENS
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 1:2200 E 4500 S
Mailing Address - Street 2:SUITE 250
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-4437
Mailing Address - Country:US
Mailing Address - Phone:801-278-5822
Mailing Address - Fax:
Practice Address - Street 1:2200 E 4500 S
Practice Address - Street 2:SUITE 250
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84117-4437
Practice Address - Country:US
Practice Address - Phone:801-278-5822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT54911223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics