Provider Demographics
NPI:1710656681
Name:MEDEROS, STEPHANIE (RDH)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:MEDEROS
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:TAVERAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:53 CHESTER ST
Mailing Address - Street 2:
Mailing Address - City:LAKE GROVE
Mailing Address - State:NY
Mailing Address - Zip Code:11755-3047
Mailing Address - Country:US
Mailing Address - Phone:631-455-2971
Mailing Address - Fax:
Practice Address - Street 1:53 CHESTER ST
Practice Address - Street 2:
Practice Address - City:LAKE GROVE
Practice Address - State:NY
Practice Address - Zip Code:11755-3047
Practice Address - Country:US
Practice Address - Phone:631-455-2971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-13
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY02746301124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty