=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124742119
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ZACHARY N. STEFAN, DMD, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2022
-----------------------------------------------------
Last Update Date | 10/03/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 54 WESTERVIEW DR
-----------------------------------------------------
City | WESTERVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43081-2682
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-794-3629
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1695 GLENN AVE APT A
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43212-2348
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-933-7045
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ZACHARY STEFAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 330-933-7045
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------