Basic Information
| Provider Information | |||||||||
| NPI: | 1407022775 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STANGER | ||||||||
| FirstName: | SERENA | ||||||||
| MiddleName: | TERESA | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LAP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2116 SW FORD ST | ||||||||
| Address2: | |||||||||
| City: | GRANTS PASS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975268324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414796393 | ||||||||
| FaxNumber: | 5414796489 | ||||||||
| Practice Location | |||||||||
| Address1: | 1035 NE 6TH ST | ||||||||
| Address2: | STE B | ||||||||
| City: | GRANTS PASS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975261298 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414796393 | ||||||||
| FaxNumber: | 5414796489 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2008 | ||||||||
| LastUpdateDate: | 05/06/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | H3673 | OR | Y | Dental Providers | Dental Hygienist |
ID Information
| ID | Type | State | Issuer | Description | 127725 | 05 | OR | MEDICAID |