Provider Demographics
NPI:1730701384
Name:WONG, STEPHANIE (DDS)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22889 SHELBURNE RD
Mailing Address - Street 2:
Mailing Address - City:SHAKER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44122-2015
Mailing Address - Country:US
Mailing Address - Phone:216-577-0193
Mailing Address - Fax:
Practice Address - Street 1:5161 WILLIAM FLYNN HWY UNIT B
Practice Address - Street 2:
Practice Address - City:GIBSONIA
Practice Address - State:PA
Practice Address - Zip Code:15044-8401
Practice Address - Country:US
Practice Address - Phone:724-939-3032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-16
Last Update Date:2020-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0426531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice