Healthcare Provider Details

I. General information

NPI: 1679573455
Provider Name (Legal Business Name): KENNETH LEE STOLER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2005
Last Update Date: 04/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 TERRYVILLE RD
PORT JEFFERSON STATION NY
11776-1372
US

IV. Provider business mailing address

132 TERRYVILLE RD P.O. BOX 222
PORT JEFFERSON STATION NY
11776-1372
US

V. Phone/Fax

Practice location:
  • Phone: 631-473-6400
  • Fax: 631-473-7297
Mailing address:
  • Phone: 631-473-6400
  • Fax: 631-473-7297

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number030286
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: