Provider Demographics
NPI:1740542315
Name:LOSMAN, STACEY BRANDE (DMD)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:BRANDE
Last Name:LOSMAN
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 1:5 ZAVATONE CT
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:NY
Mailing Address - Zip Code:10977-1721
Mailing Address - Country:US
Mailing Address - Phone:914-450-9614
Mailing Address - Fax:
Practice Address - Street 1:404 ROUTE 59
Practice Address - Street 2:
Practice Address - City:AIRMONT
Practice Address - State:NY
Practice Address - Zip Code:10952-3429
Practice Address - Country:US
Practice Address - Phone:845-893-5633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-11
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYA041621-1122300000X, 1223G0001X
NJ165481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist