Provider Demographics
NPI:1629261235
Name:JOHN J STEPANOVICH DDS
Entity Type:Organization
Organization Name:JOHN J STEPANOVICH DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:STEPANOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:616-459-1267
Mailing Address - Street 1:260 JEFFERSON AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4597
Mailing Address - Country:US
Mailing Address - Phone:616-459-1267
Mailing Address - Fax:616-459-0673
Practice Address - Street 1:260 JEFFERSON AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4597
Practice Address - Country:US
Practice Address - Phone:616-459-1267
Practice Address - Fax:616-459-0673
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-27
Last Update Date:2007-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI07553122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty