Provider Demographics
NPI:1194517490
Name:GRODECKI, STEPHANIE KRISTINE (DMD)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:KRISTINE
Last Name:GRODECKI
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 1:1050 N HANCOCK ST APT N210
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19123-2342
Mailing Address - Country:US
Mailing Address - Phone:240-372-0914
Mailing Address - Fax:
Practice Address - Street 1:2301 E ALLEGHENY AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19134-4427
Practice Address - Country:US
Practice Address - Phone:215-282-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-21
Last Update Date:2025-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0450401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice