Provider Demographics
NPI:1265553051
Name:GILLESPIE, STEPHEN T (DDS)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:T
Last Name:GILLESPIE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 N RIVERSIDE AVE
Mailing Address - Street 2:1164
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-4652
Mailing Address - Country:US
Mailing Address - Phone:541-776-6996
Mailing Address - Fax:541-776-0996
Practice Address - Street 1:1600 N RIVERSIDE AVE
Practice Address - Street 2:1164
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-4652
Practice Address - Country:US
Practice Address - Phone:541-776-6996
Practice Address - Fax:541-776-0996
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD73561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR269044Medicare ID - Type Unspecified