Provider Demographics
NPI:1679682629
Name:STEPHENS, CHRYSTAL REGINA (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHRYSTAL
Middle Name:REGINA
Last Name:STEPHENS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3295 FORNEY ST.
Mailing Address - Street 2:
Mailing Address - City:FORT JACKSON
Mailing Address - State:SC
Mailing Address - Zip Code:29207-5780
Mailing Address - Country:US
Mailing Address - Phone:803-751-6213
Mailing Address - Fax:803-750-6886
Practice Address - Street 1:3295 FORNEY ST.
Practice Address - Street 2:
Practice Address - City:FORT JACKSON
Practice Address - State:SC
Practice Address - Zip Code:29207-5780
Practice Address - Country:US
Practice Address - Phone:803-751-6213
Practice Address - Fax:803-750-6886
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC35611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice