Provider Demographics
NPI:1407873466
Name:YANDOLI, STACEY A (DMD)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:A
Last Name:YANDOLI
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 1:776 GROVE RD
Mailing Address - Street 2:
Mailing Address - City:WEST DEPTFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08086
Mailing Address - Country:US
Mailing Address - Phone:856-848-2211
Mailing Address - Fax:856-848-8630
Practice Address - Street 1:776 GROVE RD
Practice Address - Street 2:
Practice Address - City:WEST DEPTFORD
Practice Address - State:NJ
Practice Address - Zip Code:08086
Practice Address - Country:US
Practice Address - Phone:856-848-2211
Practice Address - Fax:856-848-8630
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY22542001223P0221X
NJ225421223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0109193Medicaid