Provider Demographics
NPI:1922024215
Name:O'DONNELL, STANLEY MARVIN (DMD)
Entity Type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:MARVIN
Last Name:O'DONNELL
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 1:1101 GLENEAGLES DR SW
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-6405
Mailing Address - Country:US
Mailing Address - Phone:256-881-4441
Mailing Address - Fax:256-881-4320
Practice Address - Street 1:1101 GLENEAGLES DR SW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-6405
Practice Address - Country:US
Practice Address - Phone:256-881-4441
Practice Address - Fax:256-881-4320
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3447122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL05884Medicare UPIN