Provider Demographics
NPI:1659975084
Name:TILL, STEPHANIE (DDS)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:
Last Name:TILL
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 1:1607 WOODMONT DR
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-2649
Mailing Address - Country:US
Mailing Address - Phone:540-874-8455
Mailing Address - Fax:
Practice Address - Street 1:208 PARKWAY BLVD
Practice Address - Street 2:
Practice Address - City:ELIZABETHTON
Practice Address - State:TN
Practice Address - Zip Code:37643-2845
Practice Address - Country:US
Practice Address - Phone:540-874-8455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-25
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014166851223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics