Healthcare Provider Details

I. General information

NPI: 1194517490
Provider Name (Legal Business Name): STEPHANIE KRISTINE GRODECKI DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2025
Last Update Date: 05/21/2025
Certification Date: 05/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 E ALLEGHENY AVE
PHILADELPHIA PA
19134-4427
US

IV. Provider business mailing address

1050 N HANCOCK ST APT N210
PHILADELPHIA PA
19123-2342
US

V. Phone/Fax

Practice location:
  • Phone: 215-282-8000
  • Fax:
Mailing address:
  • Phone: 240-372-0914
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS045040
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: