Provider Demographics
NPI:1790984813
Name:STANLEY, ADRIANE MEDENWALD (DMD)
Entity Type:Individual
Prefix:
First Name:ADRIANE
Middle Name:MEDENWALD
Last Name:STANLEY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 W WASHINGTON ST STE C3&4
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-2434
Mailing Address - Country:US
Mailing Address - Phone:601-856-4888
Mailing Address - Fax:601-856-8077
Practice Address - Street 1:101 W WASHINGTON ST STE C3&4
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-2434
Practice Address - Country:US
Practice Address - Phone:601-856-4888
Practice Address - Fax:601-856-8077
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-18
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3452-081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice