Provider Demographics
NPI:1356878771
Name:INLOES, STACEY IRENE (EFDA)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:IRENE
Last Name:INLOES
Suffix:
Gender:F
Credentials:EFDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18848 ROSE RD
Mailing Address - Street 2:
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-8929
Mailing Address - Country:US
Mailing Address - Phone:503-830-3518
Mailing Address - Fax:
Practice Address - Street 1:10209 SE SUNNYSIDE RD
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-9782
Practice Address - Country:US
Practice Address - Phone:503-353-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-16
Last Update Date:2017-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR113490126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant