Provider Demographics
NPI:1740643568
Name:COLE, STACY VIRGIL (DDS)
Entity type:Individual
Prefix:DR
First Name:STACY
Middle Name:VIRGIL
Last Name:COLE
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 1:4812 BRYANT IRVIN CT
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-7640
Mailing Address - Country:US
Mailing Address - Phone:817-731-9291
Mailing Address - Fax:817-737-9767
Practice Address - Street 1:4812 BRYANT IRVIN CT
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-7640
Practice Address - Country:US
Practice Address - Phone:817-731-9291
Practice Address - Fax:817-737-9767
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-30
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX114811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice