Provider Demographics
NPI:1972047470
Name:STEVENS, ELIZABETH LAURA
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:LAURA
Last Name:STEVENS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 DIAMOND MATCH RD
Mailing Address - Street 2:
Mailing Address - City:MILO
Mailing Address - State:ME
Mailing Address - Zip Code:04463-1756
Mailing Address - Country:US
Mailing Address - Phone:207-941-6550
Mailing Address - Fax:
Practice Address - Street 1:12 STILLWATER AVE
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3984
Practice Address - Country:US
Practice Address - Phone:207-941-6550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-19
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDTR5532122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist