Provider Demographics
NPI:1972796324
Name:WISNER, STELLA (DDS)
Entity Type:Individual
Prefix:DR
First Name:STELLA
Middle Name:
Last Name:WISNER
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 1:1717 W COWLES ST
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-5926
Mailing Address - Country:US
Mailing Address - Phone:907-452-8251
Mailing Address - Fax:
Practice Address - Street 1:1001 S SEASIDE AVE
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-7333
Practice Address - Country:US
Practice Address - Phone:310-732-7512
Practice Address - Fax:310-732-7519
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-20
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54571122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist