Provider Demographics
NPI:1205510930
Name:DE SOLO, STEFAN MICHAEL
Entity type:Individual
Prefix:
First Name:STEFAN
Middle Name:MICHAEL
Last Name:DE SOLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 N GATEHOUSE DR APT E
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70001-2045
Mailing Address - Country:US
Mailing Address - Phone:305-450-0066
Mailing Address - Fax:
Practice Address - Street 1:1100 FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-2715
Practice Address - Country:US
Practice Address - Phone:504-941-8199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-13
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA7518122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program