Provider Demographics
NPI:1689788515
Name:STEVENSON, JOHN WALTER (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WALTER
Last Name:STEVENSON
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 1:22 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-1524
Mailing Address - Country:US
Mailing Address - Phone:248-625-8494
Mailing Address - Fax:248-922-0476
Practice Address - Street 1:22 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-1524
Practice Address - Country:US
Practice Address - Phone:248-625-8494
Practice Address - Fax:248-922-0476
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1414606122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist