Provider Demographics
NPI:1720516453
Name:STANISIC, KERRY JO LOCKLEAR
Entity Type:Individual
Prefix:
First Name:KERRY JO
Middle Name:LOCKLEAR
Last Name:STANISIC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3315 UNIVERSITY PKWY UNIT 103
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34243-4240
Mailing Address - Country:US
Mailing Address - Phone:941-822-8165
Mailing Address - Fax:941-822-8257
Practice Address - Street 1:3315 UNIVERSITY PKWY UNIT 103
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34243-4240
Practice Address - Country:US
Practice Address - Phone:941-822-8165
Practice Address - Fax:941-822-8257
Is Sole Proprietor?:No
Enumeration Date:2017-05-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN22556122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist