Provider Demographics
NPI:1407022775
Name:STANGER, SERENA TERESA (LAP)
Entity type:Individual
Prefix:MS
First Name:SERENA
Middle Name:TERESA
Last Name:STANGER
Suffix:
Gender:F
Credentials:LAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2116 SW FORD ST
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-8324
Mailing Address - Country:US
Mailing Address - Phone:541-479-6393
Mailing Address - Fax:541-479-6489
Practice Address - Street 1:1035 NE 6TH ST
Practice Address - Street 2:STE B
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-1298
Practice Address - Country:US
Practice Address - Phone:541-479-6393
Practice Address - Fax:541-479-6489
Is Sole Proprietor?:No
Enumeration Date:2008-05-06
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH3673124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR127725Medicaid