Healthcare Provider Details

I. General information

NPI: 1922442334
Provider Name (Legal Business Name): MRS. STEPHANIE WOODS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2013
Last Update Date: 04/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

436 5TH AND TED STEVENS WAY
KOTZEBUE AK
99752
US

IV. Provider business mailing address

436 5TH AND TED STEVENS WAY
KOTZEBUE AK
99752
US

V. Phone/Fax

Practice location:
  • Phone: 907-442-7324
  • Fax:
Mailing address:
  • Phone: 907-442-7324
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code125J00000X
TaxonomyDental Therapist
License Number05019DHAT
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: