Provider Demographics
NPI:1417966078
Name:STEFANOV, MARK E (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:E
Last Name:STEFANOV
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 UNION ST
Mailing Address - Street 2:
Mailing Address - City:WINSTED
Mailing Address - State:CT
Mailing Address - Zip Code:06098
Mailing Address - Country:US
Mailing Address - Phone:860-379-6252
Mailing Address - Fax:
Practice Address - Street 1:17 UNION ST
Practice Address - Street 2:
Practice Address - City:WINSTED
Practice Address - State:CT
Practice Address - Zip Code:06098
Practice Address - Country:US
Practice Address - Phone:860-379-6252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6741122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist