Provider Demographics
NPI:1952959322
Name:STEPHENS, JUSTIN M (DMD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:M
Last Name:STEPHENS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3145 VINEYARD
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-8511
Mailing Address - Country:US
Mailing Address - Phone:903-705-9191
Mailing Address - Fax:
Practice Address - Street 1:4164 S BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-8719
Practice Address - Country:US
Practice Address - Phone:903-705-7574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-29
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX357051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice