Provider Demographics
NPI:1033385497
Name:STEFANUS SISWANTO DDS PLLC
Entity Type:Organization
Organization Name:STEFANUS SISWANTO DDS PLLC
Other - Org Name:MIDWAY FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEFANUS
Authorized Official - Middle Name:H
Authorized Official - Last Name:SISWANTO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:214-934-2198
Mailing Address - Street 1:18181 MIDWAY RD STE 500
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75287-8104
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18181 MIDWAY RD STE 500
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75287-8104
Practice Address - Country:US
Practice Address - Phone:214-934-2198
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-06
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX224401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty