Provider Demographics
NPI:1710207790
Name:MACK, STEPHEN G (DMD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:G
Last Name:MACK
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 1:1316 E INDEPENDENCE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-4262
Mailing Address - Country:US
Mailing Address - Phone:417-889-0700
Mailing Address - Fax:417-882-0706
Practice Address - Street 1:1316 E INDEPENDENCE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-4262
Practice Address - Country:US
Practice Address - Phone:417-889-0700
Practice Address - Fax:417-882-0706
Is Sole Proprietor?:No
Enumeration Date:2010-06-02
Last Update Date:2010-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010016642122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist