Provider Demographics
NPI:1083834840
Name:PATRICIA A. STAINBACK, D.M.D., P.A.
Entity Type:Organization
Organization Name:PATRICIA A. STAINBACK, D.M.D., P.A.
Other - Org Name:HEALTHY SMILES FAMILY DENTISTRY
Other - Org Type:Other Name
Authorized Official - Title/Position:SECRETARY/TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:HORACE
Authorized Official - Middle Name:
Authorized Official - Last Name:STAINBACK
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:704-720-0692
Mailing Address - Street 1:798 CHURCH ST N
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-4368
Mailing Address - Country:US
Mailing Address - Phone:704-720-0692
Mailing Address - Fax:704-720-0693
Practice Address - Street 1:798 CHURCH ST N
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-4368
Practice Address - Country:US
Practice Address - Phone:704-720-0692
Practice Address - Fax:704-720-0693
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC66371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC899001VMedicaid