Provider Demographics
NPI:1598887382
Name:STALLEY, FRED C (DDS)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:C
Last Name:STALLEY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4613 ROLLANDO DR
Mailing Address - Street 2:
Mailing Address - City:ROLLING HILLS ESTATES
Mailing Address - State:CA
Mailing Address - Zip Code:90274-1539
Mailing Address - Country:US
Mailing Address - Phone:310-378-8720
Mailing Address - Fax:
Practice Address - Street 1:2511 ARTESIA BLVD
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90278-3209
Practice Address - Country:US
Practice Address - Phone:310-542-6988
Practice Address - Fax:310-542-3182
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA280951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice