1891829651 NPI number — STEPHANIE M DELICE, P.C.

Table of content: (NPI 1891829651)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891829651 NPI number — STEPHANIE M DELICE, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STEPHANIE M DELICE, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1891829651
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/28/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3579 HIGHWAY 138 SE STE 202
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STOCKBRIDGE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30281-6807
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-474-6111
Provider Business Mailing Address Fax Number:
770-474-5897

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3579 HWY 138
Provider Second Line Business Practice Location Address:
202
Provider Business Practice Location Address City Name:
STOCKBRIDGE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30281
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-474-6111
Provider Business Practice Location Address Fax Number:
770-474-5897
Provider Enumeration Date:
03/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DELICE
Authorized Official First Name:
STEPHANIE
Authorized Official Middle Name:
M
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
770-474-6111

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  DN011843 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000925064C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 001563854 . This is a "UNITED CONCORDIA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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