Provider Demographics
NPI:1952677494
Name:STACY, THOMAS (DDS)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:STACY
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 1:5421 WOODLAWN BLVD
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55417-1921
Mailing Address - Country:US
Mailing Address - Phone:612-724-1780
Mailing Address - Fax:
Practice Address - Street 1:5421 WOODLAWN BLVD
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55417-1921
Practice Address - Country:US
Practice Address - Phone:612-724-1780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-29
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND6903122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist