Healthcare Provider Details

I. General information

NPI: 1265358881
Provider Name (Legal Business Name): STEPHANIE PUMA RDH, PHDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2026
Last Update Date: 06/26/2026
Certification Date: 06/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11079 S BELL AVE
CHICAGO IL
60643-3934
US

IV. Provider business mailing address

11079 S BELL AVE
CHICAGO IL
60643-3934
US

V. Phone/Fax

Practice location:
  • Phone: 773-960-4493
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number020.017328
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: