Provider Demographics
NPI:1376572271
Name:DELICE, STEPHANIE M (DDS)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:M
Last Name:DELICE
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 1:3579 HIGHWAY 138
Mailing Address - Street 2:SUITE 202
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-4142
Mailing Address - Country:US
Mailing Address - Phone:770-474-6111
Mailing Address - Fax:770-474-5897
Practice Address - Street 1:3579 HIGHWAY 138
Practice Address - Street 2:SUITE 202
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-4142
Practice Address - Country:US
Practice Address - Phone:770-474-6111
Practice Address - Fax:770-474-5897
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA06-160201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000925064CMedicaid