Provider Demographics
NPI:1174937270
Name:STEVENS, PAUL (DMD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:
Last Name:STEVENS
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 1:3646 E MARDIA ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-5481
Mailing Address - Country:US
Mailing Address - Phone:801-400-4533
Mailing Address - Fax:
Practice Address - Street 1:1385 N JACKSONMILL AVE
Practice Address - Street 2:
Practice Address - City:KUNA
Practice Address - State:ID
Practice Address - Zip Code:83634-2042
Practice Address - Country:US
Practice Address - Phone:208-606-4816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-17
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-5149-PD1223P0221X
ORD108771223P0221X
AK1887941223P0221X
KY9438122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist