Provider Demographics
NPI:1689257057
Name:STEVENS, SAMUEL DOMINIC (DMD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:DOMINIC
Last Name:STEVENS
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 1:4780 CLAGUE RD
Mailing Address - Street 2:
Mailing Address - City:NORTH OLMSTED
Mailing Address - State:OH
Mailing Address - Zip Code:44070-3758
Mailing Address - Country:US
Mailing Address - Phone:440-777-2757
Mailing Address - Fax:
Practice Address - Street 1:4780 CLAGUE RD
Practice Address - Street 2:
Practice Address - City:NORTH OLMSTED
Practice Address - State:OH
Practice Address - Zip Code:44070-3758
Practice Address - Country:US
Practice Address - Phone:440-777-2757
Practice Address - Fax:440-777-4479
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-03
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.026672122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist