Provider Demographics
NPI:1386795193
Name:STEPHENSON, GERALD LANE (DDS)
Entity type:Individual
Prefix:DR
First Name:GERALD
Middle Name:LANE
Last Name:STEPHENSON
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 1:3331 E. MONTCLAIR
Mailing Address - Street 2:SUITE A
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804
Mailing Address - Country:US
Mailing Address - Phone:417-886-3636
Mailing Address - Fax:417-447-1554
Practice Address - Street 1:3331 E MONTCLAIR ST
Practice Address - Street 2:SUITE A
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-4785
Practice Address - Country:US
Practice Address - Phone:417-886-3636
Practice Address - Fax:417-447-1554
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0156011223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics