Provider Demographics
NPI:1609094721
Name:FORREST, STACY OLLER (DMD)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:OLLER
Last Name:FORREST
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7900 STEVENS MILL RD # I
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28104-2929
Mailing Address - Country:US
Mailing Address - Phone:704-882-1113
Mailing Address - Fax:704-882-3711
Practice Address - Street 1:7900 STEVENS MILL RD # I
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28104-2929
Practice Address - Country:US
Practice Address - Phone:704-882-1113
Practice Address - Fax:704-882-3711
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC71301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice