Provider Demographics
NPI:1528217940
Name:WETZEL, STEPHANIE L (DDS)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:L
Last Name:WETZEL
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 1:290 BIG RUN RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-2903
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:290 BIG RUN RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-2903
Practice Address - Country:US
Practice Address - Phone:859-278-9513
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-10
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY110451223P0106X
GADN015296204E00000X, 1223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003184098BMedicaid
KY7100943890Medicaid