Provider Demographics
NPI:1285765131
Name:WEISS, STEPHEN K (DMD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:K
Last Name:WEISS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1098 OLD TOWN RD
Mailing Address - Street 2:P.O. BOX 708
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727-3727
Mailing Address - Country:US
Mailing Address - Phone:631-698-8855
Mailing Address - Fax:
Practice Address - Street 1:1098 OLD TOWN RD
Practice Address - Street 2:
Practice Address - City:CORAM
Practice Address - State:NY
Practice Address - Zip Code:11727-3727
Practice Address - Country:US
Practice Address - Phone:631-698-8855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0370651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice