Provider Demographics
NPI:1851345953
Name:STEVENSON, MARK R (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:R
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 1:6505 E 82ND ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-1598
Mailing Address - Country:US
Mailing Address - Phone:317-849-6990
Mailing Address - Fax:317-579-1404
Practice Address - Street 1:6505 E 82ND ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-5538
Practice Address - Country:US
Practice Address - Phone:317-849-6990
Practice Address - Fax:317-579-1404
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010073A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist