Provider Demographics
NPI:1427148642
Name:GREGORY N. STEVENS D.M.D. LTD
Entity type:Organization
Organization Name:GREGORY N. STEVENS D.M.D. LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:NICHOLAS
Authorized Official - Last Name:STEVENS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:630-725-3333
Mailing Address - Street 1:PO BOX 318
Mailing Address - Street 2:
Mailing Address - City:LISLE
Mailing Address - State:IL
Mailing Address - Zip Code:60532-0318
Mailing Address - Country:US
Mailing Address - Phone:630-725-3333
Mailing Address - Fax:630-725-3334
Practice Address - Street 1:5980 STATE ROUTE 53
Practice Address - Street 2:SUITEC
Practice Address - City:LISLE
Practice Address - State:IL
Practice Address - Zip Code:60532-3199
Practice Address - Country:US
Practice Address - Phone:630-725-3333
Practice Address - Fax:630-725-3334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019016917//021001238261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT38412Medicare UPIN
IL208516/K04516Medicare ID - Type Unspecified