Provider Demographics
NPI:1669902292
Name:MCDOWELL, STACEY MARIE (DMD)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:MARIE
Last Name:MCDOWELL
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 1:146 CREEKRISE PL
Mailing Address - Street 2:
Mailing Address - City:PALMETTO
Mailing Address - State:GA
Mailing Address - Zip Code:30268-2096
Mailing Address - Country:US
Mailing Address - Phone:404-884-9195
Mailing Address - Fax:
Practice Address - Street 1:865 S CARROLL RD STE C
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-7056
Practice Address - Country:US
Practice Address - Phone:770-459-4131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-15
Last Update Date:2023-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0154111223G0001X
GADN15411122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice