Provider Demographics
NPI:1730343724
Name:STEWART, CHAD RYAN (DMD)
Entity type:Individual
Prefix:DR
First Name:CHAD
Middle Name:RYAN
Last Name:STEWART
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2246 S STATE ROUTE 157 STE 125
Mailing Address - Street 2:
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-1728
Mailing Address - Country:US
Mailing Address - Phone:618-288-6262
Mailing Address - Fax:
Practice Address - Street 1:2246 S STATE ROUTE 157 STE 125
Practice Address - Street 2:
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-1728
Practice Address - Country:US
Practice Address - Phone:618-288-6262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-18
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004019268122300000X
IL019.028959122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist