Provider Demographics
NPI:1740203124
Name:STACEY, MATTHEW WARD (DDS)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:WARD
Last Name:STACEY
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 1:1200 CENTRE PARK DR
Mailing Address - Street 2:STE 100
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28805-6108
Mailing Address - Country:US
Mailing Address - Phone:828-252-3591
Mailing Address - Fax:
Practice Address - Street 1:417 BILTMORE AVE
Practice Address - Street 2:2-C DOCTORS PARK
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28801-4543
Practice Address - Country:US
Practice Address - Phone:828-252-3591
Practice Address - Fax:828-252-7591
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC71821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89902EKMedicaid