Provider Demographics
NPI:1245590553
Name:STACY, THORA JANE (CDA EFDA)
Entity Type:Individual
Prefix:
First Name:THORA
Middle Name:JANE
Last Name:STACY
Suffix:
Gender:F
Credentials:CDA EFDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4255 CORDON RD NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97305-3738
Mailing Address - Country:US
Mailing Address - Phone:503-370-4313
Mailing Address - Fax:
Practice Address - Street 1:2300 N.E. LACNCASTER DR.
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97303
Practice Address - Country:US
Practice Address - Phone:503-370-4313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-21
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant