Provider Demographics
NPI:1497819585
Name:SUSAN STACKER DDS SC
Entity Type:Organization
Organization Name:SUSAN STACKER DDS SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:STACKER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:715-845-7759
Mailing Address - Street 1:1220 6TH STREET
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54403-3550
Mailing Address - Country:US
Mailing Address - Phone:715-845-7759
Mailing Address - Fax:715-845-4509
Practice Address - Street 1:1220 6TH STREET
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54403-3550
Practice Address - Country:US
Practice Address - Phone:715-845-7759
Practice Address - Fax:715-845-4509
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI48281223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty