Provider Demographics
NPI:1679573455
Name:STOLER, KENNETH LEE (DDS)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:LEE
Last Name:STOLER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 TERRYVILLE RD
Mailing Address - Street 2:P.O. BOX 222
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-1372
Mailing Address - Country:US
Mailing Address - Phone:631-473-6400
Mailing Address - Fax:631-473-7297
Practice Address - Street 1:132 TERRYVILLE RD
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-1372
Practice Address - Country:US
Practice Address - Phone:631-473-6400
Practice Address - Fax:631-473-7297
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0302861223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYT49458Medicare UPIN
NYD2B081Medicare PIN