Provider Demographics
NPI:1528678364
Name:MARY BERNONA STEVENS DDS, PLLC
Entity type:Organization
Organization Name:MARY BERNONA STEVENS DDS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:BERNONA
Authorized Official - Last Name:STEVENS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:616-560-5740
Mailing Address - Street 1:1172 NIXON AVE NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49534-3638
Mailing Address - Country:US
Mailing Address - Phone:616-453-0644
Mailing Address - Fax:616-453-0646
Practice Address - Street 1:1172 NIXON AVE NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49534-3638
Practice Address - Country:US
Practice Address - Phone:616-453-0644
Practice Address - Fax:616-453-0646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-06
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental