Provider Demographics
NPI:1598865826
Name:SPYRISON, STEPHEN H (DDS)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:H
Last Name:SPYRISON
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 1:624 TERRA WEST DR
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-4595
Mailing Address - Country:US
Mailing Address - Phone:815-232-7012
Mailing Address - Fax:815-233-4316
Practice Address - Street 1:624 TERRA WEST DR
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-4595
Practice Address - Country:US
Practice Address - Phone:815-232-7012
Practice Address - Fax:815-233-4316
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1003839Medicaid