Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 204E00000X | Oral & Maxillofacial Surgeon | DDS25997 | CA |
Y | 204E00000X | Oral & Maxillofacial Surgeon | DN013387 | GA |
N | 204E00000X | Oral & Maxillofacial Surgeon | DN7757 | FL |
N | 204E00000X | Oral & Maxillofacial Surgeon | DNGA000215 | GA |
NPI | 1407878606 |
---|---|
Provider Name | Dr. Mark R Stevens |
First Address | Augusta, GA 30912-0001 |
Second Address | Augusta, GA 30912-0004 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/07/2006 |
Last Update Date | 22/03/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
589724798B | (05) | GA |
589724798I | (05) | GA |
UPIN NUMBER | (02) | |
ZG3387 | (05) | SC |