Provider Demographics
NPI:1316228687
Name:COLLETTA, STEPHANIE M (DDS)
Entity type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:M
Last Name:COLLETTA
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 1:1150 W 15TH ST
Mailing Address - Street 2:UNIT 234
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-3686
Mailing Address - Country:US
Mailing Address - Phone:206-660-5093
Mailing Address - Fax:
Practice Address - Street 1:10735 S CICERO AVE
Practice Address - Street 2:SUITE 107
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-5400
Practice Address - Country:US
Practice Address - Phone:708-423-4110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-31
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0288191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice