=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194165324
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHANIE IRIS GANS DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2013
-----------------------------------------------------
Last Update Date | 07/29/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 29001 CEDAR RD STE 660
-----------------------------------------------------
City | LYNDHURST
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44124-4041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-461-8200
-----------------------------------------------------
Fax | 440-461-8343
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 29001 CEDAR RD STE 660
-----------------------------------------------------
City | LYNDHURST
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44124-4041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-461-8200
-----------------------------------------------------
Fax | 440-461-8343
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 30.024011
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------