Provider Demographics
NPI:1396955092
Name:STAHL, MARK ALAN (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALAN
Last Name:STAHL
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 1:1113 WESTFIELD CT W APT C
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-1162
Mailing Address - Country:US
Mailing Address - Phone:206-743-6080
Mailing Address - Fax:
Practice Address - Street 1:6919 E 10TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-4893
Practice Address - Country:US
Practice Address - Phone:317-358-8885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2016-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010762A1223G0001X
WADE600768901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice