Provider Demographics
NPI:1992908719
Name:MAYO, STEPHEN PAUL (DDS)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:PAUL
Last Name:MAYO
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:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:BEAN STATION
Mailing Address - State:TN
Mailing Address - Zip Code:37708-0130
Mailing Address - Country:US
Mailing Address - Phone:865-993-2225
Mailing Address - Fax:
Practice Address - Street 1:1277 HWY 11W
Practice Address - Street 2:SUITE F
Practice Address - City:BEAN STATION
Practice Address - State:TN
Practice Address - Zip Code:37708
Practice Address - Country:US
Practice Address - Phone:865-993-2225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS69331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3225952Medicaid
TN0177839OtherBLUE CROSS BLUE SHIELD