Provider Demographics
NPI:1376620104
Name:WALKER, STACEY LEE (RDH)
Entity Type:Individual
Prefix:MISS
First Name:STACEY
Middle Name:LEE
Last Name:WALKER
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2854 E MEGAN ST
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-5181
Mailing Address - Country:US
Mailing Address - Phone:602-750-9938
Mailing Address - Fax:480-994-1193
Practice Address - Street 1:2854 E MEGAN ST
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-5181
Practice Address - Country:US
Practice Address - Phone:602-750-9938
Practice Address - Fax:480-994-1193
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZH4958124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist