Provider Demographics
NPI:1215571880
Name:PEDERSEN, STEPHANIE (DDS)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:PEDERSEN
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 1:4701 MIDVALE AVE N
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-6641
Mailing Address - Country:US
Mailing Address - Phone:206-547-5647
Mailing Address - Fax:
Practice Address - Street 1:4701 MIDVALE AVE N
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103-6641
Practice Address - Country:US
Practice Address - Phone:206-547-5647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-06
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE609703141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WADE60970314OtherLICENSE NUMBER