Provider Demographics
NPI:1922632694
Name:CARADINE, STANLEY
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:
Last Name:CARADINE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 277849
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60827-7849
Mailing Address - Country:US
Mailing Address - Phone:708-986-4234
Mailing Address - Fax:
Practice Address - Street 1:4017 E 2603RD RD
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:IL
Practice Address - Zip Code:60551-9502
Practice Address - Country:US
Practice Address - Phone:815-496-2181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-02
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019021871122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist