Provider Demographics
NPI:1285670067
Name:STANLEY, JOHN G (MD, DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:G
Last Name:STANLEY
Suffix:
Gender:M
Credentials:MD, DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2331 TYLER PKWY
Mailing Address - Street 2:SUITE 4
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-0871
Mailing Address - Country:US
Mailing Address - Phone:701-255-4000
Mailing Address - Fax:701-255-1992
Practice Address - Street 1:2331 TYLER PKWY
Practice Address - Street 2:SUITE 4
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-0871
Practice Address - Country:US
Practice Address - Phone:701-255-4000
Practice Address - Fax:701-255-1992
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-21
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND19831223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND41386Medicaid
ND13935Medicaid