Provider Demographics
NPI:1225195449
Name:STAKER, ROD L (DR)
Entity Type:Individual
Prefix:DR
First Name:ROD
Middle Name:L
Last Name:STAKER
Suffix:
Gender:M
Credentials:DR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 NORTH MULBERRY STREET
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44902
Mailing Address - Country:US
Mailing Address - Phone:419-524-1616
Mailing Address - Fax:
Practice Address - Street 1:61 NORTH MULBERRY STREET
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44902
Practice Address - Country:US
Practice Address - Phone:419-524-1616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH161191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice