Provider Demographics
NPI:1598973620
Name:STASIAK, THADDEUS S (DMD)
Entity Type:Individual
Prefix:DR
First Name:THADDEUS
Middle Name:S
Last Name:STASIAK
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 1:1 NORTHGATE SQ
Mailing Address - Street 2:
Mailing Address - City:GREENSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15601-1341
Mailing Address - Country:US
Mailing Address - Phone:724-832-1692
Mailing Address - Fax:724-836-0778
Practice Address - Street 1:1 NORTHGATE SQ
Practice Address - Street 2:
Practice Address - City:GREENSBURG
Practice Address - State:PA
Practice Address - Zip Code:15601-1341
Practice Address - Country:US
Practice Address - Phone:724-832-1692
Practice Address - Fax:724-836-0778
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS-022581-L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice