Basic Information
| Provider Information | |||||||||
| NPI: | 1679682629 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEPHENS | ||||||||
| FirstName: | CHRYSTAL | ||||||||
| MiddleName: | REGINA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3295 FORNEY ST. | ||||||||
| Address2: | |||||||||
| City: | FORT JACKSON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292075780 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037516213 | ||||||||
| FaxNumber: | 8037506886 | ||||||||
| Practice Location | |||||||||
| Address1: | 3295 FORNEY ST. | ||||||||
| Address2: | |||||||||
| City: | FORT JACKSON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292075780 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037516213 | ||||||||
| FaxNumber: | 8037506886 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 3561 | SC | Y | Dental Providers | Dentist | General Practice |
No ID Information.