Provider Demographics
NPI:1104842301
Name:STEFANO, LATA ROSE (DDS)
Entity Type:Individual
Prefix:DR
First Name:LATA
Middle Name:ROSE
Last Name:STEFANO
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 1:1617 W BOGART RD
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870-5787
Mailing Address - Country:US
Mailing Address - Phone:419-626-2205
Mailing Address - Fax:419-626-2274
Practice Address - Street 1:1617 W BOGART RD
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-5787
Practice Address - Country:US
Practice Address - Phone:419-626-2205
Practice Address - Fax:419-626-2274
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH200791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice