Provider Demographics
NPI:1649525213
Name:OLLOM, STEPHANIE MARIE (DDS)
Entity type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:MARIE
Last Name:OLLOM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:STEPHANIE
Other - Middle Name:MARIE
Other - Last Name:STUCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7477 RATCHFORD CT
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:OH
Mailing Address - Zip Code:43054-8970
Mailing Address - Country:US
Mailing Address - Phone:419-906-7196
Mailing Address - Fax:
Practice Address - Street 1:1245 S SUNBURY RD STE 201
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43081-9444
Practice Address - Country:US
Practice Address - Phone:614-776-0505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-19
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019029173122300000X
390200000X
OH30-248921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program