Provider Demographics
NPI:1467468371
Name:STUCKEY, MARK NOLAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:NOLAN
Last Name:STUCKEY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3550 BRIARFIELD BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-9184
Mailing Address - Country:US
Mailing Address - Phone:419-866-6985
Mailing Address - Fax:419-866-4311
Practice Address - Street 1:3550 BRIARFIELD BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-8916
Practice Address - Country:US
Practice Address - Phone:419-866-6985
Practice Address - Fax:419-866-4311
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH16965332B00000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies