Healthcare Provider Details

I. General information

NPI: 1154543775
Provider Name (Legal Business Name): STEPHEN N GELETKA D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 COLONIAL DR. SUITE 201
YOUNGSTOWN OH
44505-2163
US

IV. Provider business mailing address

17 COLONIAL DR. SUITE 201
YOUNGSTOWN OH
44505-2163
US

V. Phone/Fax

Practice location:
  • Phone: 330-759-8530
  • Fax: 330-759-8531
Mailing address:
  • Phone: 330-759-8530
  • Fax: 330-759-8531

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number30.017152
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS022508L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: