Provider Demographics
NPI:1356494165
Name:SHUSTAK, STANLEY A JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:A
Last Name:SHUSTAK
Suffix:JR
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 1:255 PARK AVE STE 509
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01609-1958
Mailing Address - Country:US
Mailing Address - Phone:508-754-7799
Mailing Address - Fax:508-754-8558
Practice Address - Street 1:255 PARK AVE STE 509
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01609-1958
Practice Address - Country:US
Practice Address - Phone:508-754-7799
Practice Address - Fax:508-754-8558
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA146771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0042941841OtherUNITED CONCORDIA
MAX04458OtherBLUE CROSS & BLUE SHIELD