Provider Demographics
NPI:1417018805
Name:DEITZ, STANLEY (DMD OMS)
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:
Last Name:DEITZ
Suffix:
Gender:M
Credentials:DMD OMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3189
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13220-3189
Mailing Address - Country:US
Mailing Address - Phone:315-454-6000
Mailing Address - Fax:315-454-8650
Practice Address - Street 1:188 CHASE AVE
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06704-2245
Practice Address - Country:US
Practice Address - Phone:203-754-3818
Practice Address - Fax:203-754-3619
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004084122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist