Provider Demographics
NPI:1598946501
Name:CASEY, STACI (DDS)
Entity Type:Individual
Prefix:MRS
First Name:STACI
Middle Name:
Last Name:CASEY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2821 ISLAND AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19153-2300
Mailing Address - Country:US
Mailing Address - Phone:215-492-9291
Mailing Address - Fax:215-492-5856
Practice Address - Street 1:2821 ISLAND AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19153-2300
Practice Address - Country:US
Practice Address - Phone:215-492-9291
Practice Address - Fax:215-492-5856
Is Sole Proprietor?:No
Enumeration Date:2007-11-19
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0353891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019435110001Medicaid