Provider Demographics
NPI:1962420182
Name:STEPHENS, JOHN RUSSELL (DDS)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:RUSSELL
Last Name:STEPHENS
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 1:2601 E ELMS RD
Mailing Address - Street 2:P.O. BOX 11022
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76542-2804
Mailing Address - Country:US
Mailing Address - Phone:254-699-4127
Mailing Address - Fax:254-699-4130
Practice Address - Street 1:2601 E ELMS RD
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76542-2804
Practice Address - Country:US
Practice Address - Phone:254-699-4127
Practice Address - Fax:254-699-4130
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12910122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXD12910OtherBC/BS
TX689845OtherUNITED CONCORDIA