Provider Demographics
NPI:1326043555
Name:HUPP, WENDY STAVRIDES (DMD)
Entity Type:Individual
Prefix:DR
First Name:WENDY
Middle Name:STAVRIDES
Last Name:HUPP
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7208 WOOLRICH RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-6527
Mailing Address - Country:US
Mailing Address - Phone:502-429-3834
Mailing Address - Fax:502-852-1220
Practice Address - Street 1:501 S PRESTON ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1701
Practice Address - Country:US
Practice Address - Phone:502-852-6353
Practice Address - Fax:502-852-1220
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA24173122300000X
KY85351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100017440Medicaid
KY9202491OtherDORAL DENTAL
KY50017591OtherPASSPORT HEALTH PLAN
KY7100017440Medicaid