Provider Demographics
NPI:1194956144
Name:STEPANCHUK, TATYANA I (DMD)
Entity type:Individual
Prefix:MRS
First Name:TATYANA
Middle Name:I
Last Name:STEPANCHUK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9000 GOLFSIDE DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-7793
Mailing Address - Country:US
Mailing Address - Phone:904-731-4343
Mailing Address - Fax:904-731-2783
Practice Address - Street 1:9000 GOLFSIDE DR
Practice Address - Street 2:SUITE B
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-7793
Practice Address - Country:US
Practice Address - Phone:904-367-1722
Practice Address - Fax:904-265-1257
Is Sole Proprietor?:No
Enumeration Date:2009-08-06
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN184781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice