Provider Demographics
NPI:1619094323
Name:SMITH, STACY (RDH)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1522 E A ST
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-2217
Mailing Address - Country:US
Mailing Address - Phone:307-233-6000
Mailing Address - Fax:307-235-6202
Practice Address - Street 1:1300 E A ST
Practice Address - Street 2:SUITE 208
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2260
Practice Address - Country:US
Practice Address - Phone:307-265-3622
Practice Address - Fax:307-265-3027
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY786124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist