Provider Demographics
NPI:1245249135
Name:GRUCHALLA, STEPHANIE GUY (DDS)
Entity type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:GUY
Last Name:GRUCHALLA
Suffix:
Gender:
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1231 27TH ST S STE A
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-8722
Mailing Address - Country:US
Mailing Address - Phone:701-235-1261
Mailing Address - Fax:701-235-1268
Practice Address - Street 1:1231 27TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-8722
Practice Address - Country:US
Practice Address - Phone:701-235-1261
Practice Address - Fax:701-235-1268
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND19571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND41376Medicaid