Provider Demographics
NPI:1063753838
Name:POON, STEPHEN (DDS, FICOI)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:POON
Suffix:
Gender:M
Credentials:DDS, FICOI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:579 NEWFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905-3302
Mailing Address - Country:US
Mailing Address - Phone:203-890-9300
Mailing Address - Fax:
Practice Address - Street 1:579 NEWFIELD AVE
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-3302
Practice Address - Country:US
Practice Address - Phone:203-890-9300
Practice Address - Fax:203-890-9250
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-04
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT12446122300000X, 1223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program