Provider Demographics
NPI:1619990140
Name:STEPHENS, DANIEL L (DDS)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:L
Last Name:STEPHENS
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 1:412 S SCHRADER ST
Mailing Address - Street 2:
Mailing Address - City:HAVANA
Mailing Address - State:IL
Mailing Address - Zip Code:62644-1356
Mailing Address - Country:US
Mailing Address - Phone:309-543-2612
Mailing Address - Fax:309-543-3531
Practice Address - Street 1:412 S SCHRADER ST
Practice Address - Street 2:
Practice Address - City:HAVANA
Practice Address - State:IL
Practice Address - Zip Code:62644-1356
Practice Address - Country:US
Practice Address - Phone:309-543-2612
Practice Address - Fax:309-543-3531
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19-16371122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist