Provider Demographics
NPI:1841905189
Name:STEPHENS, DOROTHY (LDO)
Entity type:Individual
Prefix:
First Name:DOROTHY
Middle Name:
Last Name:STEPHENS
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 DOWNSBY LN APT 102
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-6372
Mailing Address - Country:US
Mailing Address - Phone:770-547-6488
Mailing Address - Fax:
Practice Address - Street 1:1600 MALL OF GEORGIA BLVD STE 900
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30519-8746
Practice Address - Country:US
Practice Address - Phone:470-633-2914
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-20
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA022347156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician