Provider Demographics
NPI:1215206933
Name:STACEY L. NORRIS, D.M.D., P.A.
Entity Type:Organization
Organization Name:STACEY L. NORRIS, D.M.D., P.A.
Other - Org Name:MAIN STREET DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:L
Authorized Official - Last Name:NORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:704-889-7525
Mailing Address - Street 1:PO BOX 686
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28134-0686
Mailing Address - Country:US
Mailing Address - Phone:704-889-7525
Mailing Address - Fax:704-889-7528
Practice Address - Street 1:526 MAIN STREET
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28134
Practice Address - Country:US
Practice Address - Phone:704-889-7525
Practice Address - Fax:704-889-7528
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-27
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC86481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty