Provider Demographics
NPI:1154359404
Name:VICALVI, STEPHEN MARK (DDS)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:MARK
Last Name:VICALVI
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 1:10252 6200 RD
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401-8396
Mailing Address - Country:US
Mailing Address - Phone:970-901-9822
Mailing Address - Fax:
Practice Address - Street 1:10252 6200 RD
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-8396
Practice Address - Country:US
Practice Address - Phone:970-901-9822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2016-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO76031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice