Provider Demographics
NPI:1497484133
Name:JOHN, STANLEY CHACKO (DMD)
Entity Type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:CHACKO
Last Name:JOHN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2312 GRANBURY DR
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-7818
Mailing Address - Country:US
Mailing Address - Phone:214-549-5142
Mailing Address - Fax:
Practice Address - Street 1:1109 NORTHWEST HWY
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75041-5833
Practice Address - Country:US
Practice Address - Phone:214-227-4863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-08
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX386311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty