Provider Demographics
NPI:1427280395
Name:NEELY, STEPHANIE A (DDS)
Entity type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:A
Last Name:NEELY
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 1:805 N 36TH ST
Mailing Address - Street 2:STE. A
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-2979
Mailing Address - Country:US
Mailing Address - Phone:816-232-3011
Mailing Address - Fax:816-671-0205
Practice Address - Street 1:805 N 36TH ST
Practice Address - Street 2:STE. A
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-2979
Practice Address - Country:US
Practice Address - Phone:816-232-3011
Practice Address - Fax:816-671-0205
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-11
Last Update Date:2009-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20090132311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice