Provider Demographics
NPI:1215389945
Name:DR. STACYE J. HARBORTH,
Entity Type:Organization
Organization Name:DR. STACYE J. HARBORTH,
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:STACYE
Authorized Official - Middle Name:J
Authorized Official - Last Name:HARBORTH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:704-636-5802
Mailing Address - Street 1:484 JAKE ALEXANDER BLVD W
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28147-1365
Mailing Address - Country:US
Mailing Address - Phone:704-636-5802
Mailing Address - Fax:
Practice Address - Street 1:484 JAKE ALEXANDER BLVD W
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28147-1365
Practice Address - Country:US
Practice Address - Phone:704-636-5802
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-06
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10097261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental