Provider Demographics
NPI:1013379890
Name:STEFOS, MIMIKA (DDS)
Entity Type:Individual
Prefix:
First Name:MIMIKA
Middle Name:
Last Name:STEFOS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1771 PLYMOUTH RD
Mailing Address - Street 2:APT 301
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-2279
Mailing Address - Country:US
Mailing Address - Phone:248-207-4777
Mailing Address - Fax:
Practice Address - Street 1:3100 E EISENHOWER PKWY
Practice Address - Street 2:#300
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-5205
Practice Address - Country:US
Practice Address - Phone:734-971-3450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-22
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901021651122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist