Provider Demographics
NPI:1750423026
Name:UNDERWOOD, STEVEN LAWRENCE (DDS)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:LAWRENCE
Last Name:UNDERWOOD
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 1:107 THREE RIVERS EAST
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46802-1311
Mailing Address - Country:US
Mailing Address - Phone:260-426-4438
Mailing Address - Fax:
Practice Address - Street 1:107 THREE RIVERS EAST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46802-1311
Practice Address - Country:US
Practice Address - Phone:260-426-4438
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12008044A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist