Provider Demographics
NPI:1114004140
Name:STEFAN, MICHAEL A (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:STEFAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5560 GOVERNORS AVE NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-1456
Mailing Address - Country:US
Mailing Address - Phone:330-966-8409
Mailing Address - Fax:
Practice Address - Street 1:330 STOW AVE
Practice Address - Street 2:
Practice Address - City:CUYAHOGA FALLS
Practice Address - State:OH
Practice Address - Zip Code:44221-2516
Practice Address - Country:US
Practice Address - Phone:330-928-5575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH191971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice