Provider Demographics
NPI:1316029028
Name:JOHN C. STACEY DDS SC
Entity Type:Organization
Organization Name:JOHN C. STACEY DDS SC
Other - Org Name:STACEY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:STACEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:608-222-7511
Mailing Address - Street 1:858 JUPITER DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53718-2946
Mailing Address - Country:US
Mailing Address - Phone:608-222-7511
Mailing Address - Fax:608-222-9900
Practice Address - Street 1:858 JUPITER DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53718-2946
Practice Address - Country:US
Practice Address - Phone:608-222-7511
Practice Address - Fax:608-222-9900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI=========OtherTIN