Provider Demographics
NPI:1821016007
Name:STEPHENS, JOHN GORDON (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:GORDON
Last Name:STEPHENS
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 1:584 OAK HILL RD
Mailing Address - Street 2:THOMAS CHITTENDEN HEALTH CENTER
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-7103
Mailing Address - Country:US
Mailing Address - Phone:802-878-2933
Mailing Address - Fax:802-872-1162
Practice Address - Street 1:584 OAK HILL RD
Practice Address - Street 2:THOMAS CHITTENDEN HEALTH CENTER
Practice Address - City:WILLISTON
Practice Address - State:VT
Practice Address - Zip Code:05495-7103
Practice Address - Country:US
Practice Address - Phone:802-878-2933
Practice Address - Fax:802-872-1162
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT6041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT000-1776Medicaid
VT919-1776OtherPROVIDER NUMBER