Provider Demographics
NPI:1710901020
Name:STAMM, GARY R (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:R
Last Name:STAMM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4507 N. STERLING AVENUE
Mailing Address - Street 2:SUITE 306
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-3861
Mailing Address - Country:US
Mailing Address - Phone:309-685-0444
Mailing Address - Fax:309-685-1302
Practice Address - Street 1:4507 N STERLING AVE
Practice Address - Street 2:SUITE 306
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-3824
Practice Address - Country:US
Practice Address - Phone:309-685-0444
Practice Address - Fax:309-685-1302
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice