Provider Demographics
NPI:1699004085
Name:STEVENS, MICHAEL D (DMD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
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 1:8744W FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8207
Mailing Address - Country:US
Mailing Address - Phone:208-893-5000
Mailing Address - Fax:
Practice Address - Street 1:8744 W FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8207
Practice Address - Country:US
Practice Address - Phone:208-893-5000
Practice Address - Fax:208-322-3364
Is Sole Proprietor?:No
Enumeration Date:2009-12-14
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-46321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice