Provider Demographics
NPI:1952652802
Name:STIGALL, GARRETT (DDS)
Entity Type:Individual
Prefix:
First Name:GARRETT
Middle Name:
Last Name:STIGALL
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 1:3302 GASTON AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-2013
Mailing Address - Country:US
Mailing Address - Phone:214-828-8445
Mailing Address - Fax:
Practice Address - Street 1:240 DOCTORS DR
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-5018
Practice Address - Country:US
Practice Address - Phone:828-264-7842
Practice Address - Fax:828-264-0627
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-01
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX28455122300000X
NC94131223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1223S0112XMedicaid