Provider Demographics
NPI:1770664336
Name:STAVE, MITCHELL LOUIS (DMD)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:LOUIS
Last Name:STAVE
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 1:374 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:NJ
Mailing Address - Zip Code:07644-1121
Mailing Address - Country:US
Mailing Address - Phone:973-340-9047
Mailing Address - Fax:973-340-9047
Practice Address - Street 1:374 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:NJ
Practice Address - Zip Code:07644-1121
Practice Address - Country:US
Practice Address - Phone:973-340-9047
Practice Address - Fax:973-340-9047
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI146741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice