Provider Demographics
NPI:1205877495
Name:STEWART, STANLEY (DMD)
Entity type:Individual
Prefix:
First Name:STANLEY
Middle Name:
Last Name:STEWART
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 1:7401 N UNIVERSITY DR
Mailing Address - Street 2:102
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33321-2979
Mailing Address - Country:US
Mailing Address - Phone:954-721-7990
Mailing Address - Fax:954-720-9484
Practice Address - Street 1:7401 N UNIVERSITY DR
Practice Address - Street 2:102
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33321-2979
Practice Address - Country:US
Practice Address - Phone:954-721-7990
Practice Address - Fax:954-720-9484
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN0006161204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLS70701OtherUNITED CONCORDIA
FL85239AOtherBLUE CROSS BLUE SHIELD
FL85239AOtherBLUE CROSS BLUE SHIELD
FL852391Medicare ID - Type UnspecifiedPROVIDER