Provider Demographics
NPI:1104491380
Name:STEPHENSON, PANNAPORN (DDS)
Entity type:Individual
Prefix:DR
First Name:PANNAPORN
Middle Name:
Last Name:STEPHENSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MISS
Other - First Name:PANNAPORN
Other - Middle Name:
Other - Last Name:THAMMASUPAPONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:621 9TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-4241
Mailing Address - Country:US
Mailing Address - Phone:323-302-2600
Mailing Address - Fax:
Practice Address - Street 1:13173 60TH ST N
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-1056
Practice Address - Country:US
Practice Address - Phone:651-321-1007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-20
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND14550122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist