Provider Demographics
NPI:1649568130
Name:BILLY, STACI (RDHAP)
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:
Last Name:BILLY
Suffix:
Gender:F
Credentials:RDHAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4021 CALLE ABRIL
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-2603
Mailing Address - Country:US
Mailing Address - Phone:949-230-5763
Mailing Address - Fax:
Practice Address - Street 1:4021 CALLE ABRIL
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-2603
Practice Address - Country:US
Practice Address - Phone:949-230-5763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-18
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDHAP 356124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist