Provider Demographics
NPI:1760812556
Name:RICHARD J STALLER DDS PA
Entity Type:Organization
Organization Name:RICHARD J STALLER DDS PA
Other - Org Name:ADVANCED DENTISTRY SOUTH FLORIDA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:N
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-495-2099
Mailing Address - Street 1:15340 JOG ROAD SUITE 100
Mailing Address - Street 2:
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33446-6537
Mailing Address - Country:US
Mailing Address - Phone:561-495-2099
Mailing Address - Fax:
Practice Address - Street 1:15340 JOG ROAD SUITE 100
Practice Address - Street 2:
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33446-6537
Practice Address - Country:US
Practice Address - Phone:561-495-2099
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-15
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL60991223E0200X
FL108231223E0200X
FL91291223G0001X
FL91911223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty