Provider Demographics
NPI:1306877550
Name:WEATHERLY, STEPHEN GREGORY (DDS)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:GREGORY
Last Name:WEATHERLY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:S
Other - Middle Name:GREGORY
Other - Last Name:WEATHERLY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:15126 WALTERS DRIVE
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49068-9606
Mailing Address - Country:US
Mailing Address - Phone:269-781-6491
Mailing Address - Fax:
Practice Address - Street 1:111 NORTH JEFFERSON STREET
Practice Address - Street 2:SUITE 4
Practice Address - City:MARSHALL
Practice Address - State:MI
Practice Address - Zip Code:49068-1553
Practice Address - Country:US
Practice Address - Phone:269-781-7531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901014165122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist