Provider Demographics
NPI:1134287915
Name:STACK, AUDREY (DDS)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:STACK
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 1:276 CANCO RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-4351
Mailing Address - Country:US
Mailing Address - Phone:207-874-1025
Mailing Address - Fax:
Practice Address - Street 1:276 CANCO RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-4351
Practice Address - Country:US
Practice Address - Phone:207-874-1025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME3585122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME295140099Medicaid