Provider Demographics
NPI:1326135625
Name:STALEY, PHILIP KELLER (DDS)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:KELLER
Last Name:STALEY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21297 FOOTHILL BLVD
Mailing Address - Street 2:# 204
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94541
Mailing Address - Country:US
Mailing Address - Phone:510-582-1757
Mailing Address - Fax:
Practice Address - Street 1:21297 FOOTHILL BLVD
Practice Address - Street 2:# 204
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94541
Practice Address - Country:US
Practice Address - Phone:510-582-1757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA19533122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist