Provider Demographics
NPI:1518001957
Name:STERN, ILISA BETH (DMD)
Entity Type:Individual
Prefix:DR
First Name:ILISA
Middle Name:BETH
Last Name:STERN
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 1:1245 WORTHINGTON HILLS DR
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-1752
Mailing Address - Country:US
Mailing Address - Phone:770-402-3131
Mailing Address - Fax:
Practice Address - Street 1:2095 HIGHWAY 211 NW
Practice Address - Street 2:SUITE 6A
Practice Address - City:BRASELTON
Practice Address - State:GA
Practice Address - Zip Code:30517-3402
Practice Address - Country:US
Practice Address - Phone:770-868-4288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0133231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice