Provider Demographics
NPI:1720398720
Name:SU, STEPHANIE WAN-CHUAN (DMD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:WAN-CHUAN
Last Name:SU
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 1:421 W 57TH ST
Mailing Address - Street 2:APT 6F
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-1763
Mailing Address - Country:US
Mailing Address - Phone:617-306-4507
Mailing Address - Fax:
Practice Address - Street 1:79 AVENUE U
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11223-3554
Practice Address - Country:US
Practice Address - Phone:718-373-6707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-09
Last Update Date:2010-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0552641223X0400X
NJ22DI023937001223X0400X
CA592461223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics