Provider Demographics
NPI:1922787829
Name:KULKA, STEPHEN GERALD (DMD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:GERALD
Last Name:KULKA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8750 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13603-2168
Mailing Address - Country:US
Mailing Address - Phone:781-812-8479
Mailing Address - Fax:
Practice Address - Street 1:10590 ENDURING FREEDOM DR
Practice Address - Street 2:
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602-5503
Practice Address - Country:US
Practice Address - Phone:315-772-5576
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-17
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MADN1859961122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program