Provider Demographics
NPI:1891986410
Name:STEPHENS, KATIE SHEA (RDH)
Entity type:Individual
Prefix:MRS
First Name:KATIE
Middle Name:SHEA
Last Name:STEPHENS
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:INDIANOLA
Mailing Address - State:MS
Mailing Address - Zip Code:38751-2934
Mailing Address - Country:US
Mailing Address - Phone:662-931-3780
Mailing Address - Fax:
Practice Address - Street 1:211 HIGHWAY 82 E
Practice Address - Street 2:
Practice Address - City:INDIANOLA
Practice Address - State:MS
Practice Address - Zip Code:38751-2234
Practice Address - Country:US
Practice Address - Phone:662-887-3426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-08
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3692-07DH124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist