Basic Information
| Provider Information | |||||||||
| NPI: | 1558974121 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCOMAS | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 7307 E HEARTWOOD DR | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857566138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5756492400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 13410 E MARY ANN CLEVELAND WAY | ||||||||
| Address2: | |||||||||
| City: | VAIL | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856418613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203160613 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2020 | ||||||||
| LastUpdateDate: | 08/25/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | D010849 | AZ | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | D010849 | 01 | AZ | AZ BOARD OF DENTAL EXAMINERS | OTHER |