Provider Demographics
NPI:1306059993
Name:STEWART, WANDA E (DDS)
Entity type:Individual
Prefix:DR
First Name:WANDA
Middle Name:E
Last Name:STEWART
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 1:2971 US ROUTE 68 N
Mailing Address - Street 2:
Mailing Address - City:YELLOW SPRINGS
Mailing Address - State:OH
Mailing Address - Zip Code:45387-9746
Mailing Address - Country:US
Mailing Address - Phone:937-767-7313
Mailing Address - Fax:
Practice Address - Street 1:360 WILSON DR
Practice Address - Street 2:
Practice Address - City:XENIA
Practice Address - State:OH
Practice Address - Zip Code:45385-1810
Practice Address - Country:US
Practice Address - Phone:937-374-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30. 0186371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0980130Medicaid
OHFV90871Medicare ID - Type Unspecified