Provider Demographics
NPI:1679202295
Name:TRISTEZA, STANLEY (DMD)
Entity Type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:
Last Name:TRISTEZA
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 1:5204 HIGHWAY 51 N
Mailing Address - Street 2:
Mailing Address - City:SENATOBIA
Mailing Address - State:MS
Mailing Address - Zip Code:38668-1712
Mailing Address - Country:US
Mailing Address - Phone:662-562-9868
Mailing Address - Fax:662-562-9822
Practice Address - Street 1:5204 HIGHWAY 51 N
Practice Address - Street 2:
Practice Address - City:SENATOBIA
Practice Address - State:MS
Practice Address - Zip Code:38668-1712
Practice Address - Country:US
Practice Address - Phone:662-562-9868
Practice Address - Fax:662-562-9822
Is Sole Proprietor?:No
Enumeration Date:2022-06-08
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS4282-221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS4282-22OtherMS STATE LICENSE