Provider Demographics
NPI:1508180118
Name:STEPHAN, EUGENA BAZIUK (DMD)
Entity Type:Individual
Prefix:DR
First Name:EUGENA
Middle Name:BAZIUK
Last Name:STEPHAN
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 1:600 CHESTNUT STREET EXT
Mailing Address - Street 2:
Mailing Address - City:BRADFORD
Mailing Address - State:PA
Mailing Address - Zip Code:16701-5438
Mailing Address - Country:US
Mailing Address - Phone:814-362-8478
Mailing Address - Fax:
Practice Address - Street 1:600 CHESTNUT STREET EXT
Practice Address - Street 2:
Practice Address - City:BRADFORD
Practice Address - State:PA
Practice Address - Zip Code:16701-5438
Practice Address - Country:US
Practice Address - Phone:814-362-8478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY408381223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1032395030001Medicaid