Provider Demographics
NPI:1275200933
Name:STACY, JUSTIN (DMD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:STACY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:JUSTIN
Other - Middle Name:DAVID
Other - Last Name:STACY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:12413 ANGEL VALE PL
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27703-2108
Mailing Address - Country:US
Mailing Address - Phone:508-320-2125
Mailing Address - Fax:
Practice Address - Street 1:9660 FALLS OF NEUSE RD UNIT 153
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615
Practice Address - Country:US
Practice Address - Phone:919-205-0520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-30
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1859181122300000X
390200000X
NC13386122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program