Provider Demographics
NPI:1083107882
Name:STALLARD, DEREK S
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:S
Last Name:STALLARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 W ROLLING HILLS CIR APT 209
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33328-1955
Mailing Address - Country:US
Mailing Address - Phone:423-677-6940
Mailing Address - Fax:
Practice Address - Street 1:1950 S NARCOOSSEE RD
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34771-7204
Practice Address - Country:US
Practice Address - Phone:217-540-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-07
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN23428122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist