Provider Demographics
NPI:1245978667
Name:STACKHOUSE, ANESA (DMD)
Entity type:Individual
Prefix:DR
First Name:ANESA
Middle Name:
Last Name:STACKHOUSE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 BOAT CLUB LN
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29073-7237
Mailing Address - Country:US
Mailing Address - Phone:864-399-8137
Mailing Address - Fax:
Practice Address - Street 1:4760 HARD SCRABBLE RD STE 102
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29229-8630
Practice Address - Country:US
Practice Address - Phone:803-462-4554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-25
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC102251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty