Provider Demographics
NPI:1851385736
Name:RADACK, STEPHEN T III (DMD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:T
Last Name:RADACK
Suffix:III
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 1:413 E 38TH ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16504-1621
Mailing Address - Country:US
Mailing Address - Phone:814-825-6221
Mailing Address - Fax:814-825-4502
Practice Address - Street 1:413 E 38TH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16504-1621
Practice Address - Country:US
Practice Address - Phone:814-825-6221
Practice Address - Fax:814-825-4502
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-07
Last Update Date:2007-07-08
Deactivation Date:2006-03-24
Deactivation Code:
Reactivation Date:2006-04-11
Provider Licenses
StateLicense IDTaxonomies
PADS025272L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice