Provider Demographics
NPI:1902025968
Name:LITZ, STEPHANIE M (DDS, MSD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:M
Last Name:LITZ
Suffix:
Gender:F
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:124 N INDIANA ST
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46158-1503
Mailing Address - Country:US
Mailing Address - Phone:317-831-3370
Mailing Address - Fax:317-834-1012
Practice Address - Street 1:100 TOWN CENTER DR S STE A
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46158-2322
Practice Address - Country:US
Practice Address - Phone:317-831-5439
Practice Address - Fax:317-831-9750
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN120091301223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300046440Medicaid
IN100186730AMedicaid