Provider Demographics
NPI:1891014528
Name:MORIMOTO, STEPHEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:
Last Name:MORIMOTO
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 1:219 N HAMMES AVE
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-8114
Mailing Address - Country:US
Mailing Address - Phone:815-741-0095
Mailing Address - Fax:815-741-0328
Practice Address - Street 1:219 N HAMMES AVE
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-8114
Practice Address - Country:US
Practice Address - Phone:815-741-0095
Practice Address - Fax:815-741-0328
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-20
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0166751223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery