Provider Demographics
NPI:1740313105
Name:DEAN, STACY MARIE (DDS)
Entity type:Individual
Prefix:DR
First Name:STACY
Middle Name:MARIE
Last Name:DEAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 N FRANKLIN DR
Mailing Address - Street 2:SUITE 5
Mailing Address - City:WASHINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:15301-5892
Mailing Address - Country:US
Mailing Address - Phone:724-222-2256
Mailing Address - Fax:724-222-9384
Practice Address - Street 1:125 N FRANKLIN DR
Practice Address - Street 2:SUITE 5
Practice Address - City:WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:15301-5892
Practice Address - Country:US
Practice Address - Phone:724-222-2256
Practice Address - Fax:724-222-9384
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV36631223G0001X
OH30.0219011223G0001X
PADS0377861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0136695000Medicaid