Provider Demographics
NPI:1891829651
Name:STEPHANIE M DELICE, P.C.
Entity Type:Organization
Organization Name:STEPHANIE M DELICE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:DELICE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-474-6111
Mailing Address - Street 1:3579 HIGHWAY 138 SE STE 202
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-6807
Mailing Address - Country:US
Mailing Address - Phone:770-474-6111
Mailing Address - Fax:770-474-5897
Practice Address - Street 1:3579 HWY 138
Practice Address - Street 2:202
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281
Practice Address - Country:US
Practice Address - Phone:770-474-6111
Practice Address - Fax:770-474-5897
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0118431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000925064CMedicaid
GA001563854OtherUNITED CONCORDIA
GA000925064CMedicaid