Provider Demographics
NPI:1669693388
Name:WAGNER-LELEVOUR, STEPHANIE (DDS)
Entity type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:
Last Name:WAGNER-LELEVOUR
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 1:7447 WEST TALCOTT ROAD
Mailing Address - Street 2:SUITE 560
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60631
Mailing Address - Country:US
Mailing Address - Phone:773-763-5353
Mailing Address - Fax:773-573-1232
Practice Address - Street 1:7447 WEST TALCOTT ROAD
Practice Address - Street 2:SUITE 560
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60631
Practice Address - Country:US
Practice Address - Phone:773-763-5353
Practice Address - Fax:773-573-1232
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019026616122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist