Healthcare Provider Details

I. General information

NPI: 1215510086
Provider Name (Legal Business Name): STEFANEL ERIKA LEE KIM DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2021
Last Update Date: 03/05/2023
Certification Date: 03/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3741 MAIN ST
BRIDGEPORT CT
06606-3609
US

IV. Provider business mailing address

3741 MAIN ST
BRIDGEPORT CT
06606-3609
US

V. Phone/Fax

Practice location:
  • Phone: 475-282-4912
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number13220
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: