Provider Demographics
NPI:1528120771
Name:STEVENS, MICHAEL GERARD
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:GERARD
Last Name:STEVENS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2675 CENTRAL AVE
Mailing Address - Street 2:SUITE U-23
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59102-6686
Mailing Address - Country:US
Mailing Address - Phone:406-656-8300
Mailing Address - Fax:406-656-9088
Practice Address - Street 1:2675 CENTRAL AVE
Practice Address - Street 2:SUITE U-23
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59102-6686
Practice Address - Country:US
Practice Address - Phone:406-656-8300
Practice Address - Fax:406-656-9088
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT17151223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0113356Medicaid