Provider Demographics
NPI:1306001888
Name:STEVENSON, ALLAN WALKER (DDS)
Entity type:Individual
Prefix:
First Name:ALLAN
Middle Name:WALKER
Last Name:STEVENSON
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 1:206 GROVE AVE.
Mailing Address - Street 2:PO BOX 420
Mailing Address - City:PARMA
Mailing Address - State:ID
Mailing Address - Zip Code:83660
Mailing Address - Country:US
Mailing Address - Phone:208-722-6400
Mailing Address - Fax:208-722-9016
Practice Address - Street 1:206 GROVE AVE.
Practice Address - Street 2:
Practice Address - City:PARMA
Practice Address - State:ID
Practice Address - Zip Code:83660
Practice Address - Country:US
Practice Address - Phone:208-722-6400
Practice Address - Fax:208-722-9016
Is Sole Proprietor?:No
Enumeration Date:2008-07-23
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD32041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID804061600Medicaid