Provider Demographics
NPI:1437163821
Name:STEPHENS, WILLIE L (DDS)
Entity type:Individual
Prefix:DR
First Name:WILLIE
Middle Name:L
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 1:372 WASHINGTON STREET
Mailing Address - Street 2:
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02481
Mailing Address - Country:US
Mailing Address - Phone:781-235-4554
Mailing Address - Fax:781-237-2947
Practice Address - Street 1:372 WASHINGTON STREET
Practice Address - Street 2:
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02481
Practice Address - Country:US
Practice Address - Phone:781-235-4554
Practice Address - Fax:781-237-2947
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA162911223S0112X
MADN162911223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA726209OtherTUFTS HEALTH PLAN
MAX04651OtherBCBS MA
MAX04651OtherBCBS MA
MAX04651Medicare ID - Type Unspecified