Provider Demographics
NPI:1396024295
Name:GOOD, STACEY CATHLEEN (DMD)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:CATHLEEN
Last Name:GOOD
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 LINDEN DR STE 150
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601-2893
Mailing Address - Country:US
Mailing Address - Phone:540-662-4866
Mailing Address - Fax:
Practice Address - Street 1:212 LINDEN DR STE 150
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-2893
Practice Address - Country:US
Practice Address - Phone:540-662-4866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-09
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014154271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice