Provider Demographics
NPI:1700973104
Name:NETTLETON, STEPHANIE (DDS)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:NETTLETON
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 1:946 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:MASON CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50401-4202
Mailing Address - Country:US
Mailing Address - Phone:641-424-4521
Mailing Address - Fax:641-424-8403
Practice Address - Street 1:946 E STATE ST
Practice Address - Street 2:
Practice Address - City:MASON CITY
Practice Address - State:IA
Practice Address - Zip Code:50401-4202
Practice Address - Country:US
Practice Address - Phone:641-424-4521
Practice Address - Fax:641-424-8403
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA77151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA7715OtherDELTA DENTAL
867568OtherUNITED CONCORDIA
IA1109967Medicaid
IA16804OtherBLUE CROSS BLUE SHIELD