Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 5195 | VA |
NPI | 1003834466 |
---|---|
Provider Name | Dr. Pretlow Lee Stevenson JR. |
First Address | Portsmouth, VA 23707 |
Second Address | Portsmouth, VA 23707 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/07/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
005864 | BLUE CROSS INS (01) | VA |
028450 | AETNA DMO INSURANCE (01) | |
142470 | CIGNA INS (01) | VA |
322 | DOMINION INSURANCE (01) | |
4815115 | (05) | VA |