Provider Demographics
NPI:1588656359
Name:RODDY, STANLEY COOPER JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:COOPER
Last Name:RODDY
Suffix:JR
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 1:615 BELLE MEADE BLVD APT 107
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37205-3869
Mailing Address - Country:US
Mailing Address - Phone:615-352-5805
Mailing Address - Fax:615-385-3802
Practice Address - Street 1:615 BELLE MEADE BLVD. #107
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37205
Practice Address - Country:US
Practice Address - Phone:615-352-5805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2013-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS27881223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNT73977Medicare UPIN