Provider Demographics
NPI:1750588174
Name:STEPHENS, MARK LEROY (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:LEROY
Last Name:STEPHENS
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 1:930 SUNNYSLOPE RD
Mailing Address - Street 2:B-3
Mailing Address - City:HOLLISTER
Mailing Address - State:CA
Mailing Address - Zip Code:95023-5615
Mailing Address - Country:US
Mailing Address - Phone:831-637-4627
Mailing Address - Fax:831-637-7017
Practice Address - Street 1:930 SUNNYSLOPE RD
Practice Address - Street 2:B-3
Practice Address - City:HOLLISTER
Practice Address - State:CA
Practice Address - Zip Code:95023-5615
Practice Address - Country:US
Practice Address - Phone:831-637-4627
Practice Address - Fax:831-637-7017
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA379301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice