Provider Demographics
NPI:1558467399
Name:BLUME-SOPER, STACEY MICHELE (DMD)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:MICHELE
Last Name:BLUME-SOPER
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 1:644 OVERTON ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:KY
Mailing Address - Zip Code:41071-2010
Mailing Address - Country:US
Mailing Address - Phone:513-200-3844
Mailing Address - Fax:513-871-8490
Practice Address - Street 1:4030 SMITH RD
Practice Address - Street 2:SUITE 225
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45209-1957
Practice Address - Country:US
Practice Address - Phone:513-871-8488
Practice Address - Fax:513-871-8490
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY21731223G0001X
OH253871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice