Provider Demographics
NPI:1700218153
Name:JACKSON, STONA RIEDER (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:STONA
Middle Name:RIEDER
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:USA DENTAC BAVARIA
Mailing Address - Street 2:UNIT 28038
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09112
Mailing Address - Country:US
Mailing Address - Phone:01149966-283-4727
Mailing Address - Fax:
Practice Address - Street 1:USA DENTAC BAVARIA
Practice Address - Street 2:UNIT 28038
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09112
Practice Address - Country:US
Practice Address - Phone:01149966-283-4727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-07
Last Update Date:2016-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE 60399515122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist