Provider Demographics
NPI:1679688923
Name:GEORGE C. STACEY, JR. D.M.D. FAMILY DENISTRY P.C.
Entity Type:Organization
Organization Name:GEORGE C. STACEY, JR. D.M.D. FAMILY DENISTRY P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:CARROLL
Authorized Official - Last Name:STACEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:256-546-4947
Mailing Address - Street 1:938 FORREST AVE
Mailing Address - Street 2:
Mailing Address - City:GADSDEN
Mailing Address - State:AL
Mailing Address - Zip Code:35901-3623
Mailing Address - Country:US
Mailing Address - Phone:256-546-4947
Mailing Address - Fax:256-546-8846
Practice Address - Street 1:938 FORREST AVE
Practice Address - Street 2:
Practice Address - City:GADSDEN
Practice Address - State:AL
Practice Address - Zip Code:35901-3623
Practice Address - Country:US
Practice Address - Phone:256-546-4947
Practice Address - Fax:256-546-8846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5034122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL515-02634OtherBC/BS OF AL