Provider Demographics
NPI:1336220144
Name:ROBERT O STEVENS DMD, PA
Entity Type:Organization
Organization Name:ROBERT O STEVENS DMD, PA
Other - Org Name:BETHEL DENTAL GROUP
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DENTIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:ORLO
Authorized Official - Last Name:STEVENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-375-5656
Mailing Address - Street 1:10572 W BUSINESS PARK LN
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-6797
Mailing Address - Country:US
Mailing Address - Phone:208-375-5656
Mailing Address - Fax:208-375-5928
Practice Address - Street 1:10572 W BUSINESS PARK LN
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-6797
Practice Address - Country:US
Practice Address - Phone:208-375-5656
Practice Address - Fax:208-375-5928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD1807261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID43162OtherREGENCE BLUE SHIELD
ID64709OtherBLUE CROSS