Provider Demographics
NPI:1164619599
Name:STACEY - KINSEY, DMD, PC
Entity Type:Organization
Organization Name:STACEY - KINSEY, DMD, PC
Other - Org Name:WEST ATLANTA ORAL SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SEC- TREAS.
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:W
Authorized Official - Last Name:KINSEY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:770-949-3797
Mailing Address - Street 1:6043 PRESTLEY MILL RD STE A
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-2280
Mailing Address - Country:US
Mailing Address - Phone:770-949-3797
Mailing Address - Fax:770-949-9077
Practice Address - Street 1:6043 PRESTLEY MILL RD STE A
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-2280
Practice Address - Country:US
Practice Address - Phone:770-949-3797
Practice Address - Fax:770-949-9077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-01
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA90631223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty