Provider Demographics
NPI:1942204524
Name:STACEY, MICHAEL JOHN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOHN
Last Name:STACEY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 SHIRLEY RD
Mailing Address - Street 2:
Mailing Address - City:BUNKIE
Mailing Address - State:LA
Mailing Address - Zip Code:71322-1542
Mailing Address - Country:US
Mailing Address - Phone:318-346-6668
Mailing Address - Fax:318-346-6142
Practice Address - Street 1:921 SHIRLEY RD
Practice Address - Street 2:
Practice Address - City:BUNKIE
Practice Address - State:LA
Practice Address - Zip Code:71322-1542
Practice Address - Country:US
Practice Address - Phone:318-346-6668
Practice Address - Fax:318-346-6142
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-10
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3790122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1837903Medicaid