Provider Demographics
NPI:1780090563
Name:FRIESE, STACI (DDS)
Entity type:Individual
Prefix:
First Name:STACI
Middle Name:
Last Name:FRIESE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:STACI
Other - Middle Name:
Other - Last Name:SIEREN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2335 HIGHWAY 92
Mailing Address - Street 2:
Mailing Address - City:OSKALOOSA
Mailing Address - State:IA
Mailing Address - Zip Code:52577-9626
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2335 HIGHWAY 92
Practice Address - Street 2:
Practice Address - City:OSKALOOSA
Practice Address - State:IA
Practice Address - Zip Code:52577-9626
Practice Address - Country:US
Practice Address - Phone:641-673-8455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-01
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IADDS-09102122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist