Provider Demographics
NPI:1295866028
Name:STACPOOLE, CORY
Entity Type:Individual
Prefix:DR
First Name:CORY
Middle Name:
Last Name:STACPOOLE
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:COURTLAND
Other - Middle Name:
Other - Last Name:STACPOOLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:500 SUTTER ST STE 707
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94102-1116
Mailing Address - Country:US
Mailing Address - Phone:415-781-2781
Mailing Address - Fax:415-781-1782
Practice Address - Street 1:500 SUTTER ST STE 707
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94102-1116
Practice Address - Country:US
Practice Address - Phone:415-781-2781
Practice Address - Fax:415-781-1782
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA294821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice